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WAL-MART CENTRAL FILL 10-2670
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
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
1/10/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/3/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew J Wain, COO
(843) 792-8533
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/10/2017
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