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SOUTHEAST MEDICINE SHOP
DSH010001A SOUTHEAST HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHEAST HEALTH MEDICAL CENTER
Subdivision Name
SOUTHEAST HEALTH PAIN MANAGEMENT
Type
Disproportionate Share Hospital
340B ID
DSH010001A
Entity Address
208 HAVEN DRIVE
DOTHAN, AL 36301
Medicare Provider Number
010001
Outpatient Facility Provider Number
Participating Start Date
7/1/2024
Last Recertification Date
8/27/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
SOUTHEAST MEDICINE SHOP
Pharmacy Address
1108 ROSS CLARK CIRCLE
SUITE 160
DOTHAN, AL 36301
Pharmacy Comments
Contract Details
Approval Date
6/27/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
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
6/27/2024
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