Covered Entity Details

DSH110038L JOHN D ARCHBOLD MEMORIAL HOSPITAL (Terminated) - information as of 5/6/2025 11:14:48 PM

Main Details

Name

JOHN D ARCHBOLD MEMORIAL HOSPITAL

Subdivision Name

Decatur County Dialysis Facility

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110038L

Medicare Provider Number

110038

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

3/29/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/30/2016

Last Recertification Date

8/18/2016

Termination Date
Termination Reason

1/1/2018
Other

Contacts

Authorizing Official

John D. Archbold Memorial Hospital
Greg S. Hembree, CFO
(229) 228-2853

Primary Contact

John D. Archbold Memorial Hospital
Chris Newman, Vice President, Clinical and Support Services
(229) 228-2771

Addresses

Street Address

700 Gordon Avenue
Bainbridge, GA 39819

Billing Address

John D Archbold Memorial Hospital
920 Cairo Road
Thomasville, GA 31792

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated as RRC110038-05 from 1/1/2015-4/1/2016. Converted to DSH effective 4/1/2016.	03/30/2016

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
GA	000000063A
		1194779702

Shipping Addresses

Shipping Address 1

Distribution Center
83 Genesis Parkway
Thomasville, GA 31792

Shipping Address 2

John D Archbold Memorial Hospital
915 Gordon Avenue
Thomasville, GA 31792

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
DSH110038A	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD CANCER CENTER/ONCOLOGY	919 S. BROAD STREET	THOMASVILLE	GA	Active
DSH110038B	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD SPECIALTY CLINIC CAMILLA	259 US HIGHWAY 19 N	CAMILLA	GA	Active
DSH110038C	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD SPECIALTY CLINIC BAINBRIDGE	1323 East Shotwell Street	Bainbridge	GA	Active
DSH110038D	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD AMBULATORY CARE CENTER/ENDOSCOPY	947 South Broad Street	Thomasville	GA	Active
DSH110038E	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD CTR FOR WOUND MANAGEMENT	113 W HANSELL ST	THOMASVILLE	GA	Terminated
DSH110038F	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD URGENT CARE CENTER	2705 E PINETREE BLVD	THOMASVILLE	GA	Active
DSH110038G	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD SPECIALTY CLINIC BAINBRIDGE/NUCLEAR CARDIOLOGY	1323 East Shotwell Street	Bainbridge	GA	Active
DSH110038H	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	Grady County Dialysis Facility	1182 5th Street SE	Cairo	GA	Terminated
DSH110038J	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	Southwest GA Dialysis Facility	201 Old Albany Road	Thomasville	GA	Terminated
DSH110038K	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	Brooks County Dialysis Facility	101 E Davis Street	Quitman	GA	Terminated
DSH110038L	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	Decatur County Dialysis Facility	700 Gordon Avenue	Bainbridge	GA	Terminated
DSH110038M	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	Mitchell County Dialysis Facility	251 US Hwy 19 North	Camilla	GA	Terminated
DSH110038N	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	Southwest GA Dialysis Facility / Home Dialysis	201 Old Albany Road	Thomasville	GA	Terminated
DSH110038P	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD OUTPATIENT REHABILITATION	300 W HANSELL STREET	THOMASVILLE	GA	Terminated
DSH110038Q	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD CANCER CENTER/AMBULATORY INFUSION CENTER	919 S Broad Street	Thomasville	GA	Active
DSH110038R	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD AMBULATORY CARE CENTER/AMBULATORY IMAGING AND SERVICES	947 South Broad Street	Thomasville	GA	Active
DSH110038S	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD CCSG IMAGING/CARDIOLOGY	116 MIMOSA DRIVE	THOMASVILLE	GA	Active
DSH110038T	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD AMBULATORY CARE CENTER/WOMENS IMAGING AND SERVICES	947 South Broad Street	Thomasville	GA	Active
DSH110038U	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD SLEEP CENTER	114 MIMOSA DR	THOMASVILLE	GA	Active
DSH110038V	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD PHARMACOTHERAPY CLINIC	114 MIMOSA DR	THOMASVILLE	GA	Active
DSH110038W	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD IM RESIDENCY CLINIC - Internal Medicine Residency Clinic	114 MIMOSA DR	THOMASVILLE	GA	Active
DSH110038X	Child	DSH	JOHN D ARCHBOLD MEMORIAL HOSPITAL	ARCHBOLD NORTHSIDE CENTER FOR CHANGE - Outpatient Psychiatry	401 OLD ALBANY RD	THOMASVILLE	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Newman, Chris Vice President, Clinical Services John D. Archbold Memorial Hospital 2292282771	Newman, Chris Vice President, Clinical and Support Services John D. Archbold Memorial Hospital 2292282771	8/29/2024 3:39 PM
Contacts	Primary Contact	Update	Profile Change Request	Newman, Chris Vice President, Ancillary Services John D. Archbold Memorial Hospital 2292282771	Newman, Chris Vice President, Clinical Services John D. Archbold Memorial Hospital 2292282771	2/17/2021 8:31 AM
Contacts	Authorizing Official	Update	Profile Change Request	Hembree, Greg S. CFO John D. Archboold Memorial Hospital 2292282853	Hembree, Greg S. CFO John D. Archbold Memorial Hospital 2292282853	4/26/2018 6:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Newman, Chris Pharmacy Director John D. Archbold Memorial Hospital 2292282752	Newman, Chris Vice President, Ancillary Services John D. Archbold Memorial Hospital 2292282771	3/29/2018 9:50 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		10/31/2017 12:00:00 AM	11/15/2017 8:23 PM
Details	State	Update	Recertification	Active	To Be Terminated	11/15/2017 8:23 PM
Terminations	Termination Comments	Update	Recertification		Facility sold effective 11/1/2017	11/15/2017 8:23 PM
Terminations	Termination Date	Update	Recertification		1/1/2018 12:00:00 AM	11/15/2017 8:23 PM
Terminations	Termination Effective Date	Update	Recertification		11/1/2017 12:00:00 AM	11/15/2017 8:23 PM
Terminations	Termination Reason	Update	Recertification		Other	11/15/2017 8:23 PM
Details	Entity Name	Update	Recertification	JOHN D. ARCHBOLD MEMORIAL HOSPITAL	JOHN D ARCHBOLD MEMORIAL HOSPITAL	11/15/2017 8:22 PM
Contacts	Authorizing Official	Update		Hembree, Greg S. CFO 2292282853	Hembree, Greg S. CFO John D. Archboold Memorial Hospital 2292282853	10/22/2017 1:10 PM
Contacts	Primary Contact	Update		Newman, Chris Pharmacy Director 2292282752	Newman, Chris Pharmacy Director John D. Archbold Memorial Hospital 2292282752	9/29/2017 9:39 AM
Contacts	Authorizing Official	Insert			Hembree, Greg S. CFO 2292282853	1/22/2017 3:05 PM
Contacts	Primary Contact	Insert			Newman, Chris Pharmacy Director 2292282752	1/22/2017 3:05 PM
Contacts	Signed By	Insert			HIGHTOWER, CHARLES D. CFO 2292282853	1/22/2017 3:05 PM
Addresses	Main Address	Insert			700 Gordon Avenue Bainbridge, GA 39819	1/22/2017 3:02 PM
Addresses	Billing Address	Insert			John D Archbold Memorial Hospital 920 Cairo Road Thomasville, GA 31792	1/22/2017 3:02 PM
Addresses	Shipping Address	Insert			John D Archbold Memorial Hospital 915 Gordon Avenue Thomasville, GA 31792	1/22/2017 3:02 PM
Addresses	Shipping Address	Insert			Distribution Center 83 Genesis Parkway Thomasville, GA 31792	1/22/2017 3:02 PM
Details	Last Recertification Date	Update			8/18/2016 12:00:00 AM	8/18/2016 3:57 PM
Dates	Participating Approval Date	Update			3/30/2016 12:00:00 AM	3/30/2016 9:59 AM
Details	State	Update		Pending	Active	3/30/2016 9:59 AM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/30/2016 9:59 AM
Details	Comments Public	Insert			Participated as RRC110038-05 from 1/1/2015-4/1/2016. Converted to DSH effective 4/1/2016.	3/30/2016 8:51 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_58628	DSH110038L	3/30/2016 7:49 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_58628	3/29/2016 4:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/29/2016 4:11 PM
Medicaid Billing	Medicaid: Number	Insert			000000063A	3/29/2016 4:11 PM
Medicaid Billing	Medicaid: State	Insert			GA	3/29/2016 4:11 PM
Medicaid Billing	NPI: Number	Insert			1194779702	3/29/2016 4:11 PM
Details	Last Recertification Date	Insert				3/29/2016 4:11 PM
Details	Grant Number	Insert				3/29/2016 4:11 PM
Details	340B ID	Insert				3/29/2016 4:11 PM
Details	Is Authorizing Official EHB Data	Insert				3/29/2016 4:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert				3/29/2016 4:11 PM
Details	Medicare Provider Number	Insert			110038	3/29/2016 4:11 PM
Details	Entity Name	Insert			JOHN D. ARCHBOLD MEMORIAL HOSPITAL	3/29/2016 4:11 PM
Details	Program Code	Insert			DSH	3/29/2016 4:11 PM
Details	Entity Subname	Insert			Decatur County Dialysis Facility	3/29/2016 4:11 PM
Dates	Participating Approval Date	Insert				3/29/2016 4:11 PM
Details	State	Insert			Pending	3/29/2016 4:11 PM
Dates	Registration Date	Insert			3/29/2016 12:00:00 AM	3/29/2016 4:11 PM
Dates	Signed By Date	Insert			3/29/2016 12:00:00 AM	3/29/2016 4:11 PM
Dates	Start Date	Insert				3/29/2016 4:11 PM
Terminations	Termination Comments	Insert				3/29/2016 4:11 PM
Terminations	Termination Date	Insert				3/29/2016 4:11 PM
Terminations	Termination Effective Date	Insert				3/29/2016 4:11 PM
Terminations	Termination Reason	Insert				3/29/2016 4:11 PM