Yes
Coffee Regional Medical Center
1101 Ocilla Road
Douglas, GA 31533
CRMC Out-Patient Pharmacy
1101 Ocilla Road
Douglas, GA 31533
| Contract Detail | GEORGIA CVS PHARMACY, L.L.C. | DBA: CVS/PHARMACY # 04552 |
912 W. WARD ST.
| DOUGLAS | GA | 31533 | 10/01/2013 | 01/01/2014 | | 01/01/2016 | 08/01/2017 |
| Contract Detail | HARK PHARMACEUTICAL, LLC | DBA MALCOLMS DISCOUNT PHARMACY |
250 PETERSON AVE S
| DOUGLAS | GA | 31533-5237 | 04/17/2018 | 07/01/2018 | | | 04/17/2018 |
| Contract Detail | HOSPITAL DISCOUNT DRUG CENTER | HOSPITAL DISCOUNT DRUGS |
308 WESTSIDE DR
| DOUGLAS | GA | 31533-3153 | 04/17/2018 | 07/01/2018 | | | 04/17/2018 |
| Contract Detail | MALCOLMS DRUG STORE INC | |
250 S PETERSON AVE
| DOUGLAS | GA | 31533 | 12/16/2011 | 12/22/2011 | | 01/01/2016 | 08/01/2017 |
| Contract Detail | MCRAE'S PHARMACY OF DOUGLAS | INC. |
1002 WEST WARD STREET
P.O. BOX 1089
| DOUGLAS | GA | 31533 | 11/25/2011 | 11/28/2011 | | 01/01/2016 | 08/01/2017 |
| Contract Detail | MCRAES PHARMACY OF DOUGLAS INC | 1002 WARD ST W |
| DOUGLAS | GA | 31533-2251 | 04/17/2018 | 07/01/2018 | | | 04/17/2018 |
| Contract Detail | NICHOLLS PHARMACY LLC | 1003 VAN STREAT HWY |
P.O. BOX 247
| NICHOLLS | GA | 31554-5031 | 07/10/2014 | 10/01/2014 | | 03/02/2018 | 03/02/2018 |
| Contract Detail | NICHOLLS PHARMACY LLC | 1003 VAN STREAT HWY |
P.O. BOX 247
| NICHOLLS | GA | 31554-5031 | 04/17/2018 | 07/01/2018 | | | 04/17/2018 |
| Contract Detail | ROY POWELL'S DRUG STORE INC | 223 W. ASHLEY STREET |
| DOUGLAS | GA | 31533 | 12/02/2011 | 12/02/2011 | | 01/01/2016 | 08/01/2017 |
| Contract Detail | THE MEDICINE CABINET | 722 SHIRLEY AVE |
| DOUGLAS | GA | 31533 | 11/04/2011 | 11/10/2011 | | | 08/01/2017 |
| Contract Detail | THE MEDICINE CABINET - WARD STREET, LLC | 223 ASHLEY ST W |
| DOUGLAS | GA | 31533-2349 | 04/17/2018 | 07/01/2018 | | | 04/17/2018 |
| Contract Detail | THE MEDICINE CABINET OF ALMA | 102 SOUTH PIERCE STREET |
| ALMA | GA | 31510-3153 | 01/14/2015 | 04/01/2015 | | 01/01/2016 | 08/01/2017 |
| Contract Detail | WAL-MART PHARMACY 10-0593 | 1450 S.E. BOWENS MILL RD |
| DOUGLAS | GA | 31533 | 10/24/2012 | 10/24/2012 | | | 08/01/2017 |
| Contract Detail | WAL-MART PHARMACY 10-1061 | 136 EAST JARMAN ST. |
| HAZLEHURST | GA | 31539 | 10/24/2012 | 10/24/2012 | | 03/02/2018 | 03/02/2018 |
| DSH110089A | Child | DSH | COFFEE REGIONAL MEDICAL CENTER | Coffee Regional First Care | 1301 Peterson Avenue S | Douglas | GA | Active |
| DSH110089B | Child | DSH | COFFEE REGIONAL MEDICAL CENTER | CRMC Outpatient Infusion Center | 1101 Ocilla Rd | Douglas | GA | Active |
| DSH110089C | Child | DSH | COFFEE REGIONAL MEDICAL CENTER | CRMC Wound Care Clinic - Clinic | 305 Westside Drive | Douglas | GA | Active |
| Details | Last Recertification Date | Update | Recertification | 11/1/2023 10:14:01 AM | 9/8/2024 8:20:14 PM | 9/8/2024 8:20 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 12:52:30 PM | 11/1/2023 10:14:01 AM | 11/1/2023 10:14 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 11:10:48 AM | 8/31/2022 12:52:30 PM | 8/31/2022 12:52 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2020 1:08:58 PM | 8/30/2021 11:10:48 AM | 8/30/2021 11:10 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760419527 | 8/31/2020 1:08 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | GA | 8/31/2020 1:08 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1760419527 ( ) | | 8/31/2020 1:08 PM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2019 9:24:41 PM | 8/31/2020 1:08:58 PM | 8/31/2020 1:08 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Cravey, Lavonda
CFO
Coffee Regional Medical Center
9123835600 | Cravey, Lavonda
VP Corporate Revenue
Coffee Regional Medical Center
9123835600 | 8/26/2020 6:48 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2018 10:23:04 AM | 8/21/2019 9:24:41 PM | 8/21/2019 9:24 PM |
| Details | Last Recertification Date | Update | Recertification | 11/7/2017 8:57:22 AM | 8/30/2018 10:23:04 AM | 8/30/2018 10:23 AM |
| Addresses | Shipping Address | Insert | Change Request | | Coffee Regional Medical Center
1101 Ocilla Road
Douglas, GA 31533 | 3/7/2018 8:36 AM |
| Addresses | Shipping Address | Insert | Change Request | | CRMC Out-Patient Pharmacy
1101 Ocilla Road
Douglas, GA 31533 | 3/7/2018 8:36 AM |
| Contacts | Authorizing Official | Update | Change Request | PHILLIPS, WILLIAM
VP/CFO
Coffee Regional Medical Center
9123836944 | Cravey, Lavonda
CFO
Coffee Regional Medical Center
9123835600 | 12/20/2017 2:59 PM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2016 12:00:00 AM | 11/7/2017 8:57:22 AM | 11/7/2017 8:57 AM |
| Contacts | Primary Contact | Update | Recertification | Kirkland, Peggy
Director of Pharmacy
9123835609 | Kirkland, Peggy
Director of Pharmacy
Coffee Regional Medical Center
9123835609 | 10/25/2017 11:52 AM |
| Contacts | Authorizing Official | Update | | PHILLIPS, WILLIAM
VP/CFO
9123836944 | PHILLIPS, WILLIAM
VP/CFO
Coffee Regional Medical Center
9123836944 | 10/18/2017 11:05 AM |
| Addresses | Main Address | Insert | | |
1101 OCILLA ROAD
DOUGLAS, GA 31533 | 8/1/2017 3:21 PM |
| Contacts | Primary Contact | Insert | | | Kirkland, Peggy
Director of Pharmacy
9123835609 | 8/1/2017 3:21 PM |
| Contacts | Authorizing Official | Insert | | | PHILLIPS, WILLIAM
VP/CFO
9123836944 | 8/1/2017 3:21 PM |
| Details | Last Recertification Date | Update | | 8/12/2015 12:00:00 AM | 9/6/2016 12:00:00 AM | 9/6/2016 2:16 PM |
| Details | Last Recertification Date | Update | | 8/19/2014 12:00:00 AM | 8/12/2015 12:00:00 AM | 8/12/2015 3:16 PM |
| Details | Last Recertification Date | Update | | 9/10/2013 12:00:00 AM | 8/19/2014 12:00:00 AM | 8/19/2014 11:32 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 9/10/2013 12:00:00 AM | 9/10/2013 8:26 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 5/29/2012 12:02 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 00000448A | 5/29/2012 12:02 PM |
| Medicaid Billing | Medicaid: State | Insert | | | GA | 5/29/2012 12:02 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1760419527 | 5/29/2012 12:02 PM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/29/2012 12:02 PM |
| Details | Comments Public | Insert | | | 1/18/12 change zipcode from 31534 to 31533 | 1/18/2012 12:36 PM |
| Details | Last Recertification Date | Insert | | | | 3/2/2007 1:33 PM |
| Details | Grant Number | Insert | | | | 3/2/2007 1:33 PM |
| Details | 340B ID | Insert | | | DSH110089 | 3/2/2007 1:33 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 3/2/2007 1:33 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 3/2/2007 1:33 PM |
| Details | Medicare Provider Number | Insert | | | 110089 | 3/2/2007 1:33 PM |
| Details | Entity Name | Insert | | | COFFEE REGIONAL MEDICAL CENTER | 3/2/2007 1:33 PM |
| Details | Program Code | Insert | | | DSH | 3/2/2007 1:33 PM |
| Details | Entity Subname | Insert | | | | 3/2/2007 1:33 PM |
| Dates | Participating Approval Date | Insert | | | 3/2/2007 12:00:00 AM | 3/2/2007 1:33 PM |
| Details | State | Insert | | | Active | 3/2/2007 1:33 PM |
| Dates | Registration Date | Insert | | | 3/2/2007 12:00:00 AM | 3/2/2007 1:33 PM |
| Dates | Signed By Date | Insert | | | 2/27/2007 12:00:00 AM | 3/2/2007 1:33 PM |
| Dates | Start Date | Insert | | | 4/1/2007 12:00:00 AM | 3/2/2007 1:33 PM |
| Terminations | Termination Comments | Insert | | | | 3/2/2007 1:33 PM |
| Terminations | Termination Date | Insert | | | | 3/2/2007 1:33 PM |
| Terminations | Termination Effective Date | Insert | | | | 3/2/2007 1:33 PM |
| Terminations | Termination Reason | Insert | | | | 3/2/2007 1:33 PM |