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DSH010001 SOUTHEAST HEALTH MEDICAL CENTER (Terminated)
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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
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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
April 2025
April 2025
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