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CORAM ALTERNATE SITE SERVICES, INC.
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
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
9401-J SOUTHERN PINE BLVD
CHARLOTTE, NC 28273
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/21/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Matthew J Wain, COO
(843) 792-8533
Contract Pharmacy Representative
CVS Health/Specialty
Jen Jagodzinski, Senior Director, Specialty Product Development
(847) 559-4702
Signed By Date
7/17/2017
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