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ARCHBOLD PINETREE PHARMACY
DSH110038 JOHN D ARCHBOLD MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN D ARCHBOLD MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110038
Entity Address
915 Gordon Avenue
THOMASVILLE, GA 31792
Medicare Provider Number
110038
Participating Start Date
4/1/2016
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
ARCHBOLD PINETREE PHARMACY
Pharmacy Address
2705 E PINETREE BLVD STE F
THOMASVILLE, GA 31792-4875
Pharmacy Comments
Contract Details
Approval Date
3/31/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHARLES D. HIGHTOWER, CFO
(229) 228-2853
Contract Pharmacy Representative
John D. Archbold Memorial Hospital
Chris Newman, Vice President, Clinical and Support Services
(229) 228-2771
Signed By Date
3/31/2016
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