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SOUTHEAST MEDICINE SHOP
RRC010001-00 SOUTHEAST HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHEAST HEALTH MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC010001-00
Entity Address
1108 ROSS CLARK CIRCLE
DOTHAN, AL 36301
Medicare Provider Number
010001
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
SOUTHEAST MEDICINE SHOP
Pharmacy Address
1108 ROSS CLARK CIRCLE
SUITE 160
DOTHAN, AL 36301
Pharmacy Comments
Contract Details
Approval Date
11/30/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Robert Derek Miller, Senior Vice President, CFO
(334) 793-8701
Contract Pharmacy Representative
Southeast Health / Southeast Medicine Shop
Joseph Drake, Outpatient Pharmacy Manager
(334) 793-8116
Signed By Date
10/11/2023
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