Covered Entity Details

DSH110007F PHOEBE PUTNEY MEMORIAL HOSPITAL (Terminated) - information as of 6/2/2025 8:30:34 AM

Main Details

Name

PHOEBE PUTNEY MEMORIAL HOSPITAL

Subdivision Name

OUTPATIENT CLINIC AT DOUGHERTY COUNTY JAIL

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110007F

Medicare Provider Number

110007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

9/15/2010

Participating Start Date

10/1/2010

Participating Approval Date

9/20/2010

Last Recertification Date

11/13/2017

Termination Date
Termination Reason

10/1/2018
Business decision by the Covered Entity

Contacts

Authorizing Official

Phoebe Putney Memorial Hospital
Brian Church, CFO & CAO
(229) 312-4066

Primary Contact

Phoebe Putney Memorial Hospital
Randy Carver, MANAGER, PHARMACY
(229) 312-0115

Addresses

Street Address

1302 EVELYN AVENUE
ALBANY, GA 31701

Billing Address
Same as Street Address

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
Contract Detail	DIAMOND PHARMACY SERVICE	DIAMOND PHARMACY SERVICES	645 KOLTER DRIVE	INDIANA	PA	15701	04/15/2016	07/01/2016		04/30/2018	06/08/2018
Contract Detail	MAXOR NATIONAL PHARMACY SERICES CORP	DBA MAXOR CORRECTIONAL PHARMACY SERVICES	416 MARY LINDSAY POLK DRIVE SUITE 515	FRANKLIN	TN	37067-6212	11/23/2010	11/23/2010		05/31/2016	04/15/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110007A	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE CANCER CENTER	427 WEST THIRD AVENUE	ALBANY	GA	Active
DSH110007AA	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Implants	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AB	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Electroencephalography	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AC	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Electro Cardiology	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AD	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Speech Pathology	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AE	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Occupational Therapy	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AF	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Physical Therapy	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AG	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Respiratory Therapy	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AH	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Laboratory	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AJ	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Radiology-Diagnostic	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AK	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Recovery Room	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AL	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Operating Room	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AM	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Heart Cath Lab	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007AN	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE CARDIAC NUCLEAR MEDICINE	425 W THIRD AVENUE	ALBANY	GA	Active
DSH110007AP	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE PAIN MANAGEMENT CLINIC	425 WEST THIRD AVENUE	ALBANY	GA	Active
DSH110007AQ	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Vascular Services	427 W Third Avenue	Albany	GA	Active
DSH110007AR	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE DIABETES RESOURCE CENTER	425 W 3RD AVE	ALBANY	GA	Active
DSH110007AS	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE BEHAVIORAL HEALTH	500 3RD AVENUE	ALBANY	GA	Active
DSH110007AT	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE SURGICARE	425 WEST THIRD AVENUE	ALBANY	GA	Active
DSH110007AU	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	DOUGHERTY COUNTY JAIL CLINIC	1302 EVELYN AVENUE	ALBANY	GA	Terminated
DSH110007AV	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PPMH Outpatient Medical Services	427 W Third Avenue	Albany	GA	Active
DSH110007AW	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PPMH RHEUMATOLOGY	425 W 3rd Ave	Albany	GA	Active
DSH110007AX	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Digestive Disease Center	425 West Third Ave	Albany	GA	Active
DSH110007AY	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PPMH Radiation Oncology	425 W 3RD AVE., STE 50	ALBANY	GA	Active
DSH110007AZ	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	MEDICATION MANAGEMENT CLINIC - MMC	2000 PALMYRA RD	ALBANY	GA	Active
DSH110007B	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE WORTH ONCOLOGY CLINIC	807 S ISABELLA STREET	SYLVESTER	GA	Active
DSH110007BA	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Medication Management Clinic II - MMC II	2740 Ray Knight Way	Albany	GA	Approved
DSH110007E	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE HOSPICE	320 FOUNDATION LANE	ALBANY	GA	Terminated
DSH110007F	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	OUTPATIENT CLINIC AT DOUGHERTY COUNTY JAIL	1302 EVELYN AVENUE	ALBANY	GA	Terminated
DSH110007G	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PET/CT Imaging	2709 Meredyth Drive, Suite 100	Albany	GA	Active
DSH110007H	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Diagnostics and Imaging Center	2709 Meredyth Drive Suite 100	Albany	GA	Active
DSH110007J	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Cancer Center Sickle Cell Clinic	1009 North Monroe Street Suite B	Albany	GA	Terminated
DSH110007L	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	PHOEBE REHABILITATION OF SYLVESTER	1009 W. Franklin Street	Sylvester	GA	Terminated
DSH110007M	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Physical Medicine Industrial Rehab	2336 Dawson Road	Albany	GA	Terminated
DSH110007N	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Rehabilitation of Ashburn	354 E. Washington Ave	Ashburn	GA	Terminated
DSH110007P	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Rehabilition Center	2336 Dawson Road	Albany	GA	Terminated
DSH110007Q	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Digestive Health Center	2740 Ray Knight Way Suite 200	Albany	GA	Active
DSH110007R	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Pediatric Specialty Clinic	810 13th Ave	Albany	GA	Active
DSH110007T	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe Wound Care and Hyperbaric Center	803 N Jefferson Street Suite A	albany	GA	Active
DSH110007U	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Carlton Breast Health Center	427 W Third Ave, Medical Tower 2, Suite 400	Albany	GA	Active
DSH110007V	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Carlton Breast Health Center at Meredyth	2709 Meredyth Drive Suite 260	Albany	GA	Active
DSH110007W	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Emergency	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007X	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Clinic	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007Y	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Endoscopy	2000 PALMYRA RD	ALBANY	GA	Terminated
DSH110007Z	Child	DSH	PHOEBE PUTNEY MEMORIAL HOSPITAL	Phoebe North / Renal Dialysis	2000 PALMYRA RD	ALBANY	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Church, Brian CFO Phoebe Putney Memorial Hospital 2293124068	Church, Brian CFO & CAO Phoebe Putney Memorial Hospital 2293124066	9/8/2021 9:03 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		4/30/2018 12:00:00 AM	9/10/2018 8:30 AM
Details	State	Update	Recertification	Active	To Be Terminated	9/10/2018 8:30 AM
Terminations	Termination Date	Update	Recertification		10/1/2018 12:00:00 AM	9/10/2018 8:30 AM
Terminations	Termination Effective Date	Update	Recertification		8/31/2018 12:00:00 AM	9/10/2018 8:30 AM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	9/10/2018 8:30 AM
Contacts	Primary Contact	Update	Change Request	Carver, Randy Pharmacy Manager Phoebe Putney Memorial Hospital 2293120115	Carver, Randy MANAGER, PHARMACY Phoebe Putney Memorial Hospital 2293120115	6/1/2018 10:12 AM
Contacts	Primary Contact	Update	Recertification	HALVERSON, TINA DIRECTOR 2293128310	Carver, Randy Pharmacy Manager Phoebe Putney Memorial Hospital 2293120115	11/13/2017 9:54 AM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/13/2017 9:54:49 AM	11/13/2017 9:54 AM
Contacts	Authorizing Official	Update		Church, Brian CFO 2293124068	Church, Brian CFO Phoebe Putney Memorial Hospital 2293124068	10/6/2017 11:10 AM
Contacts	Authorizing Official	Insert			Church, Brian CFO 2293124068	9/30/2016 5:07 PM
Addresses	Main Address	Insert			1302 EVELYN AVENUE ALBANY, GA 31701	8/30/2016 10:55 AM
Contacts	Primary Contact	Insert			HALVERSON, TINA DIRECTOR 2293128310	8/30/2016 10:55 AM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 10:55 AM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	8/19/2015 12:00:00 AM	9/3/2015 11:10 AM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	9/8/2014 12:00:00 AM	9/8/2014 3:29 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/12/2013 12:00:00 AM	9/12/2013 11:35 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:23 AM
Details	Last Recertification Date	Insert				9/20/2010 12:24 PM
Details	Grant Number	Insert				9/20/2010 12:24 PM
Details	340B ID	Insert			DSH110007F	9/20/2010 12:24 PM
Details	Is Authorizing Official EHB Data	Insert				9/20/2010 12:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/20/2010 12:24 PM
Details	Medicare Provider Number	Insert			110007	9/20/2010 12:24 PM
Details	Entity Name	Insert			PHOEBE PUTNEY MEMORIAL HOSPITAL	9/20/2010 12:24 PM
Details	Program Code	Insert			DSH	9/20/2010 12:24 PM
Details	Entity Subname	Insert			OUTPATIENT CLINIC AT DOUGHERTY COUNTY JAIL	9/20/2010 12:24 PM
Dates	Participating Approval Date	Insert			9/20/2010 12:00:00 AM	9/20/2010 12:24 PM
Details	State	Insert			Active	9/20/2010 12:24 PM
Dates	Registration Date	Insert			9/15/2010 12:00:00 AM	9/20/2010 12:24 PM
Dates	Signed By Date	Insert			7/23/2010 12:00:00 AM	9/20/2010 12:24 PM
Dates	Start Date	Insert			10/1/2010 12:00:00 AM	9/20/2010 12:24 PM
Terminations	Termination Comments	Insert				9/20/2010 12:24 PM
Terminations	Termination Date	Insert				9/20/2010 12:24 PM
Terminations	Termination Effective Date	Insert				9/20/2010 12:24 PM
Terminations	Termination Reason	Insert				9/20/2010 12:24 PM