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SCH100106-00 DOCTORS MEMORIAL (Terminated)
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Main Details
Name
DOCTORS MEMORIAL
Subdivision Name
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH100106-00
Medicare Provider Number
100106
Additional Details
Current Program Status
Terminated
Registration Date
7/12/2019
Participating Start Date
10/1/2019
Participating Approval Date
7/23/2019
Last Recertification Date
8/23/2023
Termination Date
Termination Reason
11/16/2023
Other
Contacts
Authorizing Official
Doctors Memorial Hospital
Lauren Faison-Clark, CEO
(850) 584-0886
Primary Contact
Doctors Memorial Hospital
Bonnie Jean Ellison, Director of Pharmacy
(850) 584-0833
Addresses
Street Address
333 BYRON BUTLER PARKWAY
PERRY, FL 32347
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating start date 10/1/2016, Termination 4/1/2017, Reinstatement 10/1/2019
07/17/2019
8/29/16 Participated as a SCH from 10/1/2011 until terminated 1/1/13, participated as DSH from 1/1/2014 until terminated 7/1/16, reinstated as a SCH effective 10/1/2016
08/29/2016
10/19/11 Initially approved with erroneous start date of 1/1/12, on 10/3/11 updated start date to the value it should have had: 10/1/11;
10/19/2011
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