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SOUTH CAROLINA CVS PHARMACY, L.L.C.
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SOUTH CAROLINA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04204
301 N MAIN ST
SUMMERVILLE, SC 29483
Pharmacy Comments
Contract Details
Approval Date
4/15/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephen A. Hargett, CFO
(843) 792-6461
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
4/15/2013
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