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UPSTATE MEDICAL PHARMACY
DSH420078 Prisma Health GREENVILLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
Prisma Health GREENVILLE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420078
Entity Address
701 GROVE ROAD
GREENVILLE, SC 29605
Medicare Provider Number
420078
Participating Start Date
4/1/1999
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
UPSTATE MEDICAL PHARMACY
Pharmacy Address
EMPLOYEE PAVILION
701 GROVE RD
GREENVILLE, SC 29605
Pharmacy Comments
Contract Details
Approval Date
10/1/2004
Contract Begin Date
10/1/2004
Carve-In Effective Date
Contract Comments
10/19/07 ADMIN CORRECTION (PREV LINKED TO DSH29605)
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
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