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SOUTH CAROLINA CVS PHARMACY, L.L.C.
DSH420069 CLARENDON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CLARENDON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420069
Entity Address
10 HOSPITAL STREET
MANNING, SC 29102
Medicare Provider Number
420069
Participating Start Date
1/1/2005
Last Recertification Date
8/28/2015
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
SOUTH CAROLINA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03597
119 WEST BOYCE STREET
MANNING, SC 29102
Pharmacy Comments
Contract Details
Approval Date
4/10/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Contacts
Covered Entity Signing Official
EDWARD R. FRYE JR., CEO
(803) 435-3239
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
4/10/2013
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