Covered Entity Details

DSH110007AT PHOEBE PUTNEY MEMORIAL HOSPITAL (Active) - information as of 5/2/2025 10:37:01 PM

Main Details

Name

PHOEBE PUTNEY MEMORIAL HOSPITAL

Subdivision Name

PHOEBE SURGICARE

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH110007AT

Medicare Provider Number

110007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/15/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/30/2019

Last Recertification Date

8/28/2024

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

425 WEST THIRD AVENUE
2ND FLOOR, MEDICAL TOWER 1
ALBANY, GA 31701-1941

Billing Address

Phoebe Putney Memorial Hospital
417 W Third Avenue
Albany, GA 31701-1943

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
GA	000001482A	1992789721
FL	913855200	1992789721
AL	PHO0007N	1992789721

Shipping Addresses

Shipping Address 1

Phoebe Putney Memorial Hospital
417 W Third Avenue
Albany, GA 31701-1943

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
Details	Last Recertification Date	Update	Recertification	8/29/2023 7:27:19 AM	8/28/2024 3:51:29 PM	8/28/2024 3:51 PM
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	Last Recertification Date	Update	Recertification	9/15/2022 3:01:22 PM	8/29/2023 7:27:19 AM	8/29/2023 7:27 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	Q051178 (TN)		9/15/2022 3:01 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992789721 (TN)		9/15/2022 3:01 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 6:23:56 PM	9/15/2022 3:01:22 PM	9/15/2022 3:01 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 3:49:06 PM	9/9/2021 6:23:56 PM	9/9/2021 6:23 PM
Details	Entity Subname	Update	Recertification	PHOEBE SURGICARE - OP Surgery	PHOEBE SURGICARE	9/9/2021 6:23 PM
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
Contacts	Signed By	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
Medicaid Billing	NPI: State	Update	Recertification		GA	8/28/2020 3:49 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992789721	8/28/2020 3:49 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/28/2020 3:49 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992789721	8/28/2020 3:49 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/28/2020 3:49 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992789721	8/28/2020 3:49 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/28/2020 3:49 PM
Details	Last Recertification Date	Update	Recertification		8/28/2020 3:49:06 PM	8/28/2020 3:49 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
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/9/2019 11:31 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q051178	12/9/2019 11:31 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	12/9/2019 11:31 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 6:53 AM
Contacts	Signed By	Insert	New Registration		Church, Brian CFO Phoebe Putney Memorial Hospital 2293124068	10/30/2019 2:38 PM
Details	340B ID	Update	New Registration		DSH110007AT	10/30/2019 2:38 PM
Details	Entity Subname	Update	New Registration	PHOEBE SURGICARE	PHOEBE SURGICARE - OP Surgery	10/30/2019 2:38 PM
Dates	Participating Approval Date	Update	New Registration		10/30/2019 2:38:22 PM	10/30/2019 2:38 PM
Details	State	Update	New Registration	Pending	Approved	10/30/2019 2:38 PM
Dates	Signed By Date	Update	New Registration		10/15/2019 11:28:02 AM	10/30/2019 2:38 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/30/2019 2:38 PM
Addresses	Main Address	Insert	New Registration		425 WEST THIRD AVENUE 2ND FLOOR, MEDICAL TOWER 1 ALBANY, GA 31701-1941	10/15/2019 9:05 AM
Addresses	Billing Address	Insert	New Registration		Phoebe Putney Memorial Hospital 417 W Third Avenue Albany, GA 31701-1943	10/15/2019 9:05 AM
Addresses	Shipping Address	Insert	New Registration		Phoebe Putney Memorial Hospital 417 W Third Avenue Albany, GA 31701-1943	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000001482A	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		913855200	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		PHO0007N	10/15/2019 9:05 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	10/15/2019 9:05 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992789721	10/15/2019 9:05 AM
Contacts	Authorizing Official	Insert	New Registration		Church, Brian CFO Phoebe Putney Memorial Hospital 2293124068	10/15/2019 9:05 AM
Contacts	Primary Contact	Insert	New Registration		Carver, Randy MANAGER, PHARMACY Phoebe Putney Memorial Hospital 2293120115	10/15/2019 9:05 AM
Details	Last Recertification Date	Insert	New Registration			10/15/2019 9:05 AM
Details	Grant Number	Insert	New Registration			10/15/2019 9:05 AM
Details	340B ID	Insert	New Registration			10/15/2019 9:05 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/15/2019 9:05 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/15/2019 9:05 AM
Details	Medicare Provider Number	Insert	New Registration		110007	10/15/2019 9:05 AM
Details	Entity Name	Insert	New Registration		PHOEBE PUTNEY MEMORIAL HOSPITAL	10/15/2019 9:05 AM
Details	Program Code	Insert	New Registration		DSH	10/15/2019 9:05 AM
Details	Entity Subname	Insert	New Registration		PHOEBE SURGICARE	10/15/2019 9:05 AM
Dates	Participating Approval Date	Insert	New Registration			10/15/2019 9:05 AM
Details	State	Insert	New Registration		Pending	10/15/2019 9:05 AM
Dates	Registration Date	Insert	New Registration		10/15/2019 9:05:59 AM	10/15/2019 9:05 AM
Dates	Signed By Date	Insert	New Registration			10/15/2019 9:05 AM
Dates	Start Date	Insert	New Registration			10/15/2019 9:05 AM
Terminations	Termination Comments	Insert	New Registration			10/15/2019 9:05 AM
Terminations	Termination Date	Insert	New Registration			10/15/2019 9:05 AM
Terminations	Termination Effective Date	Insert	New Registration			10/15/2019 9:05 AM
Terminations	Termination Reason	Insert	New Registration			10/15/2019 9:05 AM