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MAXOR NATIONAL PHARMACY SERICES CORP
DSH110007F PHOEBE PUTNEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PHOEBE PUTNEY MEMORIAL HOSPITAL
Subdivision Name
OUTPATIENT CLINIC AT DOUGHERTY COUNTY JAIL
Type
Disproportionate Share Hospital
340B ID
DSH110007F
Entity Address
1302 EVELYN AVENUE
ALBANY, GA 31701
Medicare Provider Number
110007
Outpatient Facility Provider Number
Participating Start Date
10/1/2010
Last Recertification Date
11/13/2017
Entity Termination Date
10/1/2018
Pharmacy Details
Pharmacy Name
MAXOR NATIONAL PHARMACY SERICES CORP
Pharmacy Address
DBA MAXOR CORRECTIONAL PHARMACY SERVICES
416 MARY LINDSAY POLK DRIVE
SUITE 515
FRANKLIN, TN 37067-6212
Pharmacy Comments
Contract Details
Approval Date
11/23/2010
Contract Begin Date
11/23/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
10/25/2010
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