Covered Entity Details

DSH110007W PHOEBE PUTNEY MEMORIAL HOSPITAL (Terminated) - information as of 5/2/2025 10:42:30 PM

Main Details

Name

PHOEBE PUTNEY MEMORIAL HOSPITAL

Subdivision Name

Phoebe North / Emergency

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110007W

Medicare Provider Number

110007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/7/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/15/2015

Last Recertification Date

9/8/2021

Termination Date
Termination Reason

4/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

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

Primary Contact

Phoebe Putney Health Systems
Torey Alaine Jones, 340B Program Pharmacy Manager
(229) 312-2177

Addresses

Street Address

2000 PALMYRA RD
ALBANY, GA 31701-1528

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?
Yes

State	Medicaid Number	NPI Number
TN	Q051178	1992789721
GA	000001416A	1992789721
FL	913855200	1992789721
AL	PHO0007N	1992789721

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
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	Primary Contact	Update	Profile Change Request	Jones, Torey Alaine Corporate 340B Program Pharmacy Manager Phoebe Putney Health Systems 2293122177	Jones, Torey Alaine 340B Program Pharmacy Manager Phoebe Putney Health Systems 2293122177	8/28/2024 3:14 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/21/2021 12:00:00 AM	1/19/2022 7:56 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/19/2022 7:56 AM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	1/19/2022 7:56 AM
Terminations	Termination Effective Date	Update	Termination Request		12/31/2021 12:00:00 AM	1/19/2022 7:56 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	1/19/2022 7:56 AM
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	Last Recertification Date	Update	Recertification	8/28/2020 3:47:27 PM	9/8/2021 8:21:13 AM	9/8/2021 8:21 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1992789721	8/28/2020 3:47 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/28/2020 3:47 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992789721	8/28/2020 3:47 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/28/2020 3:47 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992789721	8/28/2020 3:47 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/28/2020 3:47 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	8/28/2020 3:47 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 7:29:38 PM	8/28/2020 3:47:27 PM	8/28/2020 3:47 PM
Contacts	Primary Contact	Update	Profile Change Request	Jones, Torey Alaine Pharmacy Manager Phoebe Putney Memorial Hospital 2294342177	Jones, Torey Alaine Corporate 340B Program Pharmacy Manager Phoebe Putney Health Systems 2293122177	4/14/2020 12:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/9/2019 11:29 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q051178	12/9/2019 11:29 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	12/9/2019 11:29 AM
Contacts	Primary Contact	Update	Change Request	Carver, Randy MANAGER, PHARMACY Phoebe Putney Memorial Hospital 2293120115	Jones, Torey Alaine Pharmacy Manager Phoebe Putney Memorial Hospital 2294342177	12/6/2019 7:00 AM
Details	Last Recertification Date	Update	Recertification	9/7/2018 3:14:40 PM	9/11/2019 7:29:38 PM	9/11/2019 7:29 PM
Details	Last Recertification Date	Update	Recertification	11/13/2017 10:01:26 AM	9/7/2018 3:14:40 PM	9/7/2018 3:14 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	0000001416A	000001416A	6/1/2018 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/1/2018 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		913855200	6/1/2018 10:39 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	6/1/2018 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/1/2018 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		PHO0007N	6/1/2018 10:39 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	6/1/2018 10:39 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 10:39 AM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/13/2017 10:01:26 AM	11/13/2017 10:01 AM
Contacts	Primary Contact	Update	Recertification	Carver, Randy Pharmacy Manager 2293120115	Carver, Randy Pharmacy Manager Phoebe Putney Memorial Hospital 2293120115	11/13/2017 9:32 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
Contacts	Signed By	Insert			loudermilk, kerry CFO 2293124100	8/30/2016 2:36 PM
Contacts	Primary Contact	Insert			Carver, Randy Pharmacy Manager 2293120115	8/30/2016 2:36 PM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 10:55 AM
Addresses	Main Address	Insert			2000 PALMYRA RD ALBANY, GA 31701-1528	8/30/2016 10:55 AM
Details	Last Recertification Date	Update			9/3/2015 12:00:00 AM	9/3/2015 11:10 AM
Dates	Participating Approval Date	Update			5/15/2015 12:00:00 AM	5/15/2015 2:34 PM
Details	State	Update		Pending	Active	5/15/2015 2:34 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/15/2015 2:34 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_50763	DSH110007W	5/7/2015 2:57 PM
Details	Entity Subname	Update		PHOEBE PUTNEY MEMORIAL HOSPTIAL / Phoebe North Emergency	Phoebe North / Emergency	5/7/2015 2:57 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_50763	4/7/2015 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/7/2015 1:08 PM
Medicaid Billing	Medicaid: Number	Insert			0000001416A	4/7/2015 1:08 PM
Medicaid Billing	Medicaid: State	Insert			GA	4/7/2015 1:08 PM
Medicaid Billing	NPI: Number	Insert			1992789721	4/7/2015 1:08 PM
Details	Last Recertification Date	Insert				4/7/2015 1:08 PM
Details	Grant Number	Insert				4/7/2015 1:08 PM
Details	340B ID	Insert				4/7/2015 1:08 PM
Details	Is Authorizing Official EHB Data	Insert				4/7/2015 1:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/7/2015 1:08 PM
Details	Medicare Provider Number	Insert			110007	4/7/2015 1:08 PM
Details	Entity Name	Insert			PHOEBE PUTNEY MEMORIAL HOSPITAL	4/7/2015 1:08 PM
Details	Program Code	Insert			DSH	4/7/2015 1:08 PM
Details	Entity Subname	Insert			PHOEBE PUTNEY MEMORIAL HOSPTIAL / Phoebe North Emergency	4/7/2015 1:08 PM
Dates	Participating Approval Date	Insert				4/7/2015 1:08 PM
Details	State	Insert			Pending	4/7/2015 1:08 PM
Dates	Registration Date	Insert			4/7/2015 12:00:00 AM	4/7/2015 1:08 PM
Dates	Signed By Date	Insert			4/7/2015 12:00:00 AM	4/7/2015 1:08 PM
Dates	Start Date	Insert				4/7/2015 1:08 PM
Terminations	Termination Comments	Insert				4/7/2015 1:08 PM
Terminations	Termination Date	Insert				4/7/2015 1:08 PM
Terminations	Termination Effective Date	Insert				4/7/2015 1:08 PM
Terminations	Termination Reason	Insert				4/7/2015 1:08 PM