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WINN-DIXIE PHARMACY
DSH010001 SOUTHEAST HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHEAST HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010001
Entity Address
1108 ROSS CLARK CIRCLE
DOTHAN, AL 36301
Medicare Provider Number
010001
Participating Start Date
7/1/2024
Last Recertification Date
8/26/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WINN-DIXIE PHARMACY
Pharmacy Address
DBA WINN-DIXIE PHARMACY #422
3850 W. MAIN STREET
DOTHAN, AL 36305
Pharmacy Comments
Contract Details
Approval Date
10/16/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DEREK R. MILLER, SR. VP FINANCE, CFO
(334) 793-8815
Contract Pharmacy Representative
Curtis Hartin, Director of Pharmacy Managed Care
(904) 370-7776
Signed By Date
10/16/2014
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