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MEDICINE CABINET OF LAKE CITY
DSH420066A LAKE CITY COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
LAKE CITY COMMUNITY HOSPITAL
Subdivision Name
PEE DEE FAMILY PRACTICE - LAKE CITY
Type
Disproportionate Share Hospital
340B ID
DSH420066A
Entity Address
276 North Ron McNair Blvd
LAKE CITY, SC 29560
Medicare Provider Number
420066
Outpatient Facility Provider Number
Participating Start Date
10/1/2009
Last Recertification Date
8/26/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
MEDICINE CABINET OF LAKE CITY
Pharmacy Address
319 MERCY ST
LAKE CITY, SC 29560-2331
Pharmacy Comments
Contract Details
Approval Date
3/10/2010
Contract Begin Date
3/10/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/15/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
TERRY BLACKMAN, OWNER
(843) 374-2825
Signed By Date
2/9/2010
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