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SOUTH CAROLINA CVS PHARMACY, L.L.C.
DSH420018 PRISMA HEALTH RICHLAND HOSPITAL
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Covered Entity Details
Entity Name
PRISMA HEALTH RICHLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420018
Entity Address
5 Richland Medical Park Drive
COLUMBIA, SC 29203
Medicare Provider Number
420018
Participating Start Date
8/1/1993
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SOUTH CAROLINA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05596
4627 NORTH MAIN STREET
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
2/28/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/18/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David F. Lee, Director of Financial Forecasting
(803) 296-3632
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
1/14/2013
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