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DIAMOND PHARMACY SERVICE
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
DIAMOND PHARMACY SERVICE
Pharmacy Address
DIAMOND PHARMACY SERVICES
645 KOLTER DRIVE
INDIANA, PA 15701
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brian Church, CFO & CAO
(229) 312-4066
Contract Pharmacy Representative
Signed By Date
4/15/2016
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