Covered Entity Details

DSH110095V TIFT REGIONAL HEALTH SYSTEM, INC (Approved) - information as of 4/28/2025 1:42:57 AM

Main Details

Name

TIFT REGIONAL HEALTH SYSTEM, INC

Subdivision Name

Tift Regional Pain Management Center - Pain Management

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110095V

Medicare Provider Number

110095

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/9/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/14/2025

Last Recertification Date

Contacts

Authorizing Official

Tift Regional Health System
Troy Buren Brooks, SVP/CFO
(229) 353-3397

Primary Contact

Tift Regional Health System, Inc.
Robert Evan Nix, Director of Pharmacy
(229) 353-6298

Addresses

Street Address

2227 Highway 41 North
Tifton, GA 31794

Billing Address

Tift Regional Medical Center
PO Box 747
Tifton, GA 31793

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110095A	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Anita Stewart Oncology Center	1623 Madison Ave	Tifton	GA	Active
DSH110095B	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	DBA Tift Regional Medical Center - Outpatient Dialysis Center	1010 Edgefield Drive	Tifton	GA	Active
DSH110095C	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	W Camp: MRI - Diagnostic Imaging	2225 Hwy 41 North	Tifton	GA	Active
DSH110095D	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	W Camp: Cardio Vasc - Cardiology	2225 Hwy 41 North	Tifton	GA	Active
DSH110095E	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	W Campus: Endoscopy - Operating Room	2225 Hwy 41 North	Tifton	GA	Active
DSH110095F	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Medical Home - Primary Care	907 E. 18th St.	Tifton	GA	Active
DSH110095G	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Sleep Study Lab - Sleep Lab	1493 Kennedy Rd	Tifton	GA	Active
DSH110095H	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	W Campus: Cardiac Ultrasd - Cardiac Ultrasound	2225 Hwy 41 North	Tifton	GA	Active
DSH110095J	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Hospice - Hospice	618 N. Central Ave.	Tifton	GA	Active
DSH110095K	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Urology OR - Operating Room	1815 Old Ocilla Rd	Tifton	GA	Active
DSH110095L	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	GSM OR - Operating Room	1610 John Orr Drive	Tifton	GA	Active
DSH110095M	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Internal Medicine at Southwell Medical Clinic - Internal Medicine	2225 Highway 41 North	Tifton	GA	Approved
DSH110095N	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Cardiology at Southwell Medical Clinic - Cardiology	2225 Highway 41 North	Tifton	GA	Approved
DSH110095P	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Pulmonary Medicine at Southwell Medical Clinic - Pulmonology	2225 Highway 41 North	Tifton	GA	Approved
DSH110095Q	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Gastroenterology at Southwell Medical Clinic - Gastroenterology	2225 Highway 41 North	Tifton	GA	Approved
DSH110095R	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Psychiatry at Southwell Medical Clinic - Psychiatry	2225 US Highway 41 North	Tifton	GA	Approved
DSH110095S	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	ExpressCare at Southwell Medical Clinic - Urgent Care	2225 Highway 41 North	Tifton	GA	Approved
DSH110095T	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Neurology at Southwell Medical Clinic - Neurology	2227 Highway 41 North	Tifton	GA	Approved
DSH110095U	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Arthritis & Osteoporosis Center of South Georgia - Rheumatology	2227 Highway 41 North	Tifton	GA	Approved
DSH110095V	Child	DSH	TIFT REGIONAL HEALTH SYSTEM, INC	Tift Regional Pain Management Center - Pain Management	2227 Highway 41 North	Tifton	GA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Brooks, Troy Buren SVP/CFO Tift Regional Health System 2293533397	4/14/2025 8:38 AM
Details	340B ID	Update	New Registration		DSH110095V	4/14/2025 8:38 AM
Details	Entity Name	Update	New Registration	TIFT REGIONAL MEDICAL CENTER	TIFT REGIONAL HEALTH SYSTEM, INC	4/14/2025 8:38 AM
Details	Entity Subname	Update	New Registration	Tift Regional Pain Management Center	Tift Regional Pain Management Center - Pain Management	4/14/2025 8:38 AM
Dates	Participating Approval Date	Update	New Registration		4/14/2025 8:38:24 AM	4/14/2025 8:38 AM
Details	State	Update	New Registration	Pending	Approved	4/14/2025 8:38 AM
Dates	Signed By Date	Update	New Registration		4/9/2025 3:45:54 PM	4/14/2025 8:38 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/14/2025 8:38 AM
Addresses	Main Address	Insert	New Registration		2227 Highway 41 North Tifton, GA 31794	4/9/2025 12:53 PM
Addresses	Billing Address	Insert	New Registration		Tift Regional Medical Center PO Box 747 Tifton, GA 31793	4/9/2025 12:53 PM
Contacts	Authorizing Official	Insert	New Registration		Brooks, Troy Buren SVP/CFO Tift Regional Health System 2293533397	4/9/2025 12:53 PM
Contacts	Primary Contact	Insert	New Registration		Nix, Robert Evan Director of Pharmacy Tift Regional Health System, Inc. 2293536298	4/9/2025 12:53 PM
Details	Assistance Received From Date	Insert	New Registration			4/9/2025 12:53 PM
Details	Assistance Received To Date	Insert	New Registration			4/9/2025 12:53 PM
Details	Last Recertification Date	Insert	New Registration			4/9/2025 12:53 PM
Details	Grant Number	Insert	New Registration			4/9/2025 12:53 PM
Details	340B ID	Insert	New Registration			4/9/2025 12:53 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/9/2025 12:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/9/2025 12:53 PM
Details	Medicare Provider Number	Insert	New Registration		110095	4/9/2025 12:53 PM
Details	Entity Name	Insert	New Registration		TIFT REGIONAL MEDICAL CENTER	4/9/2025 12:53 PM
Details	NOFO Number	Insert	New Registration			4/9/2025 12:53 PM
Details	Program Code	Insert	New Registration		DSH	4/9/2025 12:53 PM
Details	Entity Subname	Insert	New Registration		Tift Regional Pain Management Center	4/9/2025 12:53 PM
Dates	Participating Approval Date	Insert	New Registration			4/9/2025 12:53 PM
Details	State	Insert	New Registration		Pending	4/9/2025 12:53 PM
Dates	Registration Date	Insert	New Registration		4/9/2025 12:53:07 PM	4/9/2025 12:53 PM
Dates	Signed By Date	Insert	New Registration			4/9/2025 12:53 PM
Dates	Start Date	Insert	New Registration			4/9/2025 12:53 PM
Terminations	Termination Comments	Insert	New Registration			4/9/2025 12:53 PM
Terminations	Termination Date	Insert	New Registration			4/9/2025 12:53 PM
Terminations	Termination Effective Date	Insert	New Registration			4/9/2025 12:53 PM
Terminations	Termination Reason	Insert	New Registration			4/9/2025 12:53 PM