Covered Entity Details

DSH010001 SOUTHEAST HEALTH MEDICAL CENTER (Terminated) - information as of 6/21/2025 12:09:56 AM

Main Details

Name

SOUTHEAST HEALTH MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH010001

Medicare Provider Number

010001

Additional Details

Current Program Status

Terminated

Registration Date

5/10/2024

Participating Start Date

7/1/2024

Participating Approval Date

5/14/2024

Last Recertification Date

8/26/2024

Termination Date
Termination Reason

4/1/2025
Change of covered entity type

Contacts

Authorizing Official

Southeast Health Medical Center
Robert Derek Miller, Senior Vice President, CFO
(334) 793-8701

Primary Contact

Southeast Health
Jacey Cox, Director of Pharmacy
(334) 793-8113

Addresses

Street Address

1108 ROSS CLARK CIRCLE
DOTHAN, AL 36301

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (04/01/2005) until terminated effective date: (01/01/2024); reinstatement effective date: (07/1/2024)	05/14/2024
12/31/09 ADDED SHIP TO	01/21/2010

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
AL	HOS0001H,208387	1164403861,1568990125
MS	08376021	1164403861
FL	0102067-0	1164403861
GA	000001735A	1164403861

Shipping Addresses

Shipping Address 1

SOUTHEAST HEALTH MEDICAL CENTER
1108 ROSS CLARK CIRCLE
DOTHAN, AL 36301

Shipping Address 2

Southeast Medicine Shop
1108 Ross Clark Circle
Suite 160
Dothan, AL 36301

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ALABAMA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04878	1955 EAST MAIN STREET	DOTHAN	AL	36301	10/15/2014	01/01/2015	02/28/2017	03/08/2017
Contract Detail	ALABAMA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04919	1270 WEST MAIN STREET	DOTHAN	AL	36301	10/15/2014	01/01/2015	02/28/2017	03/08/2017
Contract Detail	ALABAMA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07179	5730 W. MAIN ST.	DOTHAN	AL	36305	10/15/2014	01/01/2015	09/30/2015	03/29/2016
Contract Detail	BIOPLUS SPECIALTY INFUSION AL LLC	2511 ROSS CLARK CIR		DOTHAN	AL	36301	04/14/2017	07/01/2017	12/18/2017	12/18/2017
Contract Detail	BIOPLUS SPECIALTY INFUSION AL LLC	2511 ROSS CLARK CIR		DOTHAN	AL	36301	07/17/2018	10/01/2018	12/11/2019	12/12/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/15/2022	07/01/2022	01/01/2024	01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/15/2022	07/01/2022	01/01/2024	01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/15/2022	07/01/2022	01/01/2024	01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	06/27/2024	07/01/2024	04/01/2025	04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	06/27/2024	07/01/2024	04/01/2025	04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	06/27/2024	07/01/2024	04/01/2025	04/01/2025
Contract Detail	BOWEN PHARMACY	110 HEALTHEAST DR		DOTHAN	AL	36303	03/30/2013	04/01/2013	12/31/2015	03/29/2016
Contract Detail	BOWEN PHARMACY	110 HEALTHEAST DR		DOTHAN	AL	36303	04/14/2017	07/01/2017	10/31/2019	12/12/2019
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/14/2017	07/01/2017	05/02/2019	05/20/2019
Contract Detail	CIRCLE PHARMACY	2021 ALEXANDER DR		DOTHAN	AL	36301	03/30/2013	04/01/2013	12/31/2015	03/29/2016
Contract Detail	CVS TN DISTRIBUTION, LLC	10017 KINGSTON PIKE		KNOXVILLE	TN	37922	10/15/2014	01/01/2015	02/28/2017	03/08/2017
Contract Detail	DALTON PHARMACY	141 S DALTON ST	PO BOX 279	SLOCOMB	AL	36375	04/10/2017	07/01/2017	12/11/2019	12/12/2019
Contract Detail	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	04/15/2022	07/01/2022	01/01/2024	01/01/2024
Contract Detail	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	06/27/2024	07/01/2024	04/01/2025	04/01/2025
Contract Detail	EXACT CARE PHARMACY	DDCRX, LLC	2701 HIGHPOINT OAKS DR STE 100	LEWISVILLE	TX	75067-3896	04/15/2022	07/01/2022	08/29/2023	09/26/2023
Contract Detail	EXACT CARE PHARMACY, LLC	8333 ROCKSIDE RD		CLEVELAND	OH	44125	04/15/2022	07/01/2022	08/29/2023	09/26/2023
Contract Detail	JACKS DRUGS DOTHAN	1909 HONEYSUCKLE RD STE 1	SOUTHWIND MEDICAL PARK	DOTHAN	AL	36305	03/30/2013	04/01/2013	12/31/2015	03/29/2016
Contract Detail	K MART PHARMACY 3082		2185 REEVES STREET	DOTHAN	AL	36303	07/12/2017	10/01/2017	07/01/2017	12/18/2017
Contract Detail	PUBLIX ALABAMA, LLC	PUBLIX PHARMACY #1377	4650 WEST MAIN STREET, SUITE 700	DOTHAN	AL	36305	01/14/2019	04/01/2019	03/13/2021	03/18/2021
Contract Detail	PUBLIX ALABAMA, LLC	PUBLIX PHARMACY #1375	1620 ROSS CLARK CIRCLE	DOTHAN	AL	36301	01/14/2019	04/01/2019	03/13/2021	03/18/2021
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX CENTRAL PHARMACY #3201	2424 ORLANDO CENTRAL PARKWAY	ORLANDO	FL	32809	01/14/2019	04/01/2019	03/13/2021	03/18/2021
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3213	1950 SAND LAKE RD, BLDG #5	ORLANDO	FL	32809	01/14/2019	04/01/2019	03/13/2021	03/18/2021
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/15/2022	07/01/2022	01/01/2024	01/01/2024
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	06/27/2024	07/01/2024	04/01/2025	04/01/2025
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/15/2022	07/01/2022	01/01/2024	01/01/2024
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	06/27/2024	07/01/2024	04/01/2025	04/01/2025
Contract Detail	SOUTHEAST MEDICINE SHOP	1108 ROSS CLARK CIRCLE	SUITE 160	DOTHAN	AL	36301	07/12/2017	10/01/2017	01/01/2024	01/01/2024
Contract Detail	SOUTHEAST MEDICINE SHOP	1108 ROSS CLARK CIRCLE	SUITE 160	DOTHAN	AL	36301	06/27/2024	07/01/2024	10/24/2024	10/30/2024
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/09/2014	01/01/2015	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-0604	4310 MONTGOMERY HWY		DOTHAN	AL	36303	10/09/2014	01/01/2015	01/02/2016	05/26/2016
Contract Detail	WAL-MART PHARMACY 10-0604	4310 MONTGOMERY HWY		DOTHAN	AL	36303	01/13/2017	04/01/2017	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-0723	1420 U.S. HWY 231 SOUTH		TROY	AL	36081	01/13/2017	04/01/2017	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-0734	600 BOLL WEEVIL CIRCLE		ENTERPRISE	AL	36330	10/09/2014	01/01/2015	12/31/2015	03/29/2016
Contract Detail	WAL-MART PHARMACY 10-0734	600 BOLL WEEVIL CIRCLE		ENTERPRISE	AL	36330	01/13/2017	04/01/2017	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-0740	1537 HWY 231 SOUTH		OZARK	AL	36360	10/09/2014	01/01/2015	09/06/2016	10/04/2016
Contract Detail	WAL-MART PHARMACY 10-0740	1537 HWY 231 SOUTH		OZARK	AL	36360	01/13/2017	04/01/2017	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-1063	1608 W MAGNOLIA AVE		GENEVA	AL	36340	01/13/2017	04/01/2017	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-2114	1621 MAIN STREET		CHIPLEY	FL	32428	10/09/2014	01/01/2015	12/31/2015	03/29/2016
Contract Detail	WAL-MART PHARMACY 10-2534	3300 S OATES ST		DOTHAN (SOUTH)	AL	36301	10/09/2014	01/01/2015	04/08/2022	04/14/2022
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/09/2014	01/01/2015	04/08/2022	04/14/2022
Contract Detail	WALGREEN CO	DBA: WALGREENS #11098	100 ELBA HWY	TROY	AL	36079	12/05/2011	12/05/2011	05/02/2019	05/20/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07404	2041 E MAIN STREET	DOTHAN	AL	36301	12/05/2011	12/05/2011	05/02/2019	05/20/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07405	2940 WEST MAIN STREET	DOTHAN	AL	36305	12/05/2011	12/05/2011	05/02/2019	05/20/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09256	900 RUCKER BLVD	ENTERPRISE	AL	36330-2160	12/05/2011	12/05/2011	05/02/2019	05/20/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13111	3574 MONTGOMERY HWY	DOTHAN	AL	36303	12/05/2011	12/05/2011	05/02/2019	05/20/2019
Contract Detail	WALMART PHARMACY 10-5769	3871 WEST MAIN STREET		DOTHAN	AL	36305	01/13/2017	04/01/2017	04/08/2022	04/14/2022
Contract Detail	WINN-DIXIE #454	2131 ROSS CLARK CIRCLE		DOTHAN	AL	36301	10/16/2014	01/01/2015	12/31/2015	03/29/2016
Contract Detail	WINN-DIXIE PHARMACY	DBA WINN-DIXIE PHARMACY #422	3850 W. MAIN STREET	DOTHAN	AL	36305	10/16/2014	01/01/2015	12/31/2015	03/29/2016
Contract Detail	WINN-DIXIE PHARMACY	DBA WINN-DIXIE PHARMACY #426	1571 WESTGATE PARKWAY	DOTHAN	AL	36303	10/16/2014	01/01/2015	12/31/2015	03/29/2016
Contract Detail	WINN-DIXIE PHARMACY	DBA WINN-DIXIE PHARMACY #457	1151 ROSS CLARK CIRCLE	DOTHAN	AL	36301	10/16/2014	01/01/2015	12/31/2015	03/29/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH010001A	Child	DSH	SOUTHEAST HEALTH MEDICAL CENTER	SOUTHEAST HEALTH PAIN MANAGEMENT	208 HAVEN DRIVE	DOTHAN	AL	Terminated
DSH010001B	Child	DSH	SOUTHEAST HEALTH MEDICAL CENTER	Southeast Health Wound Care	1908 Fairview Ave	Dothan	AL	Terminated
DSH010001C	Child	DSH	SOUTHEAST ALABAMA MEDICAL CENTER	Southeast Cancer Center - Hematology & Oncology	1118 Ross Clark Circle	Dothan	AL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2025 12:00:00 AM	1/27/2025 9:22 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	1/27/2025 9:22 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2025 12:00:00 AM	1/27/2025 9:22 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2025 12:00:00 AM	1/27/2025 9:22 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	1/27/2025 9:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/5/2024 3:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		208387	12/5/2024 3:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	12/5/2024 3:46 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1568990125	12/5/2024 3:46 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	12/5/2024 3:46 PM
Addresses	Shipping Address	Insert	Change Request		Southeast Medicine Shop 1108 Ross Clark Circle Suite 160 Dothan, AL 36301	10/24/2024 8:39 AM
Details	Last Recertification Date	Update	Recertification		8/26/2024 4:32:17 PM	8/26/2024 4:32 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Addresses	Main Address	Update	Hospital Type Change Request	1108 ROSS CLARK CIRCLE DOTHAN, AL 36301-3024	1108 ROSS CLARK CIRCLE DOTHAN, AL 36301	5/14/2024 8:51 AM
Contacts	Signed By	Insert	Hospital Type Change Request		Miller, Robert Derek Senior Vice President, CFO Southeast Health Medical Center 3347938701	5/14/2024 8:51 AM
Details	Last Recertification Date	Update	Hospital Type Change Request	8/28/2023 3:51:43 PM		5/14/2024 8:51 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request	1/1/2024 12:00:00 AM		5/14/2024 8:51 AM
Dates	Participating Approval Date	Update	Hospital Type Change Request	10/17/2007 12:00:00 AM	5/14/2024 8:51:55 AM	5/14/2024 8:51 AM
Details	State	Update	Hospital Type Change Request	Terminated	Approved	5/14/2024 8:51 AM
Dates	Registration Date	Update	Hospital Type Change Request	10/17/2007 12:00:00 AM	5/10/2024 3:57:36 PM	5/14/2024 8:51 AM
Dates	Signed By Date	Update	Hospital Type Change Request	2/21/2005 12:00:00 AM	5/13/2024 9:51:28 AM	5/14/2024 8:51 AM
Dates	Start Date	Update	Hospital Type Change Request	4/1/2005 12:00:00 AM	7/1/2024 12:00:00 AM	5/14/2024 8:51 AM
Terminations	Termination Date	Update	Hospital Type Change Request	1/1/2024 12:00:00 AM		5/14/2024 8:51 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request	1/1/2024 12:00:00 AM		5/14/2024 8:51 AM
Terminations	Termination Reason	Update	Hospital Type Change Request	Change of covered entity type		5/14/2024 8:51 AM
Details	Comments Public	Insert	Hospital Type Change Request		Participating from effective date: (04/01/2005) until terminated effective date: (01/01/2024); reinstatement effective date: (07/1/2024)	5/14/2024 6:51 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	11/30/2023 8:29 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	11/30/2023 8:29 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	11/30/2023 8:29 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	11/30/2023 8:29 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	11/30/2023 8:29 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 12:08:48 PM	8/28/2023 3:51:43 PM	8/28/2023 3:51 PM
Contacts	Primary Contact	Update	PC Change Request	Cox, Jacey Director of Pharmacy Southeast Health 3347938113	Cox, Jacey Director of Pharmacy Southeast Health 3347938113	2/27/2023 5:23 PM
Contacts	Authorizing Official	Update	AO Change Request	MILLER, DEREK R. SR. VP FINANCE, CFO Southeast Alabama Medical Center 3347938815	Miller, Robert Derek Senior Vice President, CFO Southeast Health Medical Center 3347938701	2/23/2023 4:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/12/2022 12:08 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		08376021	9/12/2022 12:08 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/12/2022 12:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1164403861	9/12/2022 12:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/12/2022 12:08 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 10:31:51 AM	9/12/2022 12:08:48 PM	9/12/2022 12:08 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 8:18:46 AM	8/19/2021 10:31:51 AM	8/19/2021 10:31 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164403861	9/10/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/10/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164403861	9/10/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/10/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1164403861	9/10/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/10/2020 8:18 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1164403861 ( )		9/10/2020 8:18 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 2:27:53 PM	9/10/2020 8:18:46 AM	9/10/2020 8:18 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 10:43:48 AM	8/29/2019 2:27:53 PM	8/29/2019 2:27 PM
Contacts	Primary Contact	Update	Change Request	Ezell, Jessica 340B Program Coordinator Southeast Alabama Medical Center 3347938113-4683	Cox, Jacey Director of Pharmacy Southeast Health 3347938113	3/12/2019 2:54 PM
Addresses	Shipping Address	Insert	Change Request		SOUTHEAST HEALTH MEDICAL CENTER 1108 ROSS CLARK CIRCLE DOTHAN, AL 36301	9/28/2018 1:39 PM
Addresses	Shipping Address	Delete	Change Request	SOUTHEAST ALABAMA MEDICAL CENTER 1108 ROSS CLARK CIRCLE DOTHAN, AL 36301		9/28/2018 1:39 PM
Details	Entity Name	Update	Change Request	SOUTHEAST ALABAMA MEDICAL CENTER	SOUTHEAST HEALTH MEDICAL CENTER	9/28/2018 1:39 PM
Details	Last Recertification Date	Update	Recertification	11/21/2017 11:47:44 AM	8/23/2018 10:43:48 AM	8/23/2018 10:43 AM
Contacts	Primary Contact	Insert	Recertification		Ezell, Jessica 340B Program Coordinator Southeast Alabama Medical Center 3347938113-4683	11/21/2017 11:47 AM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/21/2017 11:47:44 AM	11/21/2017 11:47 AM
Contacts	Authorizing Official	Update	New Registration	MILLER, DEREK R. SR. VP FINANCE, CFO 3347938815	MILLER, DEREK R. SR. VP FINANCE, CFO Southeast Alabama Medical Center 3347938815	10/4/2017 4:50 PM
Contacts	Authorizing Official	Insert			MILLER, DEREK R. SR. VP FINANCE, CFO 3347938815	7/12/2017 1:29 PM
Addresses	Main Address	Insert			1108 ROSS CLARK CIRCLE DOTHAN, AL 36301-3024	10/5/2016 3:26 PM
Addresses	Shipping Address	Insert			SOUTHEAST ALABAMA MEDICAL CENTER 1108 ROSS CLARK CIRCLE DOTHAN, AL 36301	10/5/2016 3:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 4:50 PM
Medicaid Billing	Medicaid: Number	Insert			0102067-0	9/1/2016 4:50 PM
Medicaid Billing	Medicaid: State	Insert			FL	9/1/2016 4:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 4:50 PM
Medicaid Billing	Medicaid: Number	Insert			000001735A	9/1/2016 4:50 PM
Medicaid Billing	Medicaid: State	Insert			GA	9/1/2016 4:50 PM
Details	Last Recertification Date	Update		8/28/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 4:50 PM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/28/2015 12:00:00 AM	8/28/2015 5:06 PM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/19/2014 12:00:00 AM	8/19/2014 11:12 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 12:00:00 AM	8/30/2013 3:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2013 3:41 PM
Medicaid Billing	Medicaid: Number	Insert			HOS0001H	1/15/2013 3:41 PM
Medicaid Billing	Medicaid: State	Insert			AL	1/15/2013 3:41 PM
Medicaid Billing	NPI: Number	Insert			1164403861	1/15/2013 3:41 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 7:32 AM
Details	Last Recertification Date	Insert				1/21/2010 2:48 PM
Details	Grant Number	Insert				1/21/2010 2:48 PM
Details	340B ID	Insert			DSH010001	1/21/2010 2:48 PM
Details	Is Authorizing Official EHB Data	Insert				1/21/2010 2:48 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/21/2010 2:48 PM
Details	Medicare Provider Number	Insert			010001	1/21/2010 2:48 PM
Details	Entity Name	Insert			SOUTHEAST ALABAMA MEDICAL CENTER	1/21/2010 2:48 PM
Details	Program Code	Insert			DSH	1/21/2010 2:48 PM
Details	Entity Subname	Insert				1/21/2010 2:48 PM
Dates	Participating Approval Date	Insert			10/17/2007 12:00:00 AM	1/21/2010 2:48 PM
Details	State	Insert			Active	1/21/2010 2:48 PM
Dates	Registration Date	Insert			10/17/2007 12:00:00 AM	1/21/2010 2:48 PM
Dates	Signed By Date	Insert			2/21/2005 12:00:00 AM	1/21/2010 2:48 PM
Dates	Start Date	Insert			4/1/2005 12:00:00 AM	1/21/2010 2:48 PM
Terminations	Termination Comments	Insert				1/21/2010 2:48 PM
Terminations	Termination Date	Insert				1/21/2010 2:48 PM
Terminations	Termination Effective Date	Insert				1/21/2010 2:48 PM
Terminations	Termination Reason	Insert				1/21/2010 2:48 PM
Details	Comments Public	Insert			12/31/09 ADDED SHIP TO	1/21/2010 2:48 PM