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COLONY DISCOUNT DRUGS INC
DSH110073 DORMINY MEDICAL CENTER
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Covered Entity Details
Entity Name
DORMINY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110073
Entity Address
200 PERRY HOUSE ROAD
FITZGERALD, GA 31750
Medicare Provider Number
110073
Participating Start Date
9/9/2005
Last Recertification Date
9/7/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
COLONY DISCOUNT DRUGS INC
Pharmacy Address
502 S GRANT ST
FITZGERALD, GA 31750
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paige Wynn, COO / CFO
(229) 468-3845
Contract Pharmacy Representative
Colony Discount Drugs, Inc
Lucas Brown, Manager/PIC
(229) 423-9801
Signed By Date
1/15/2020
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