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  5. Tri-County Medical Center, Inc.

Tri-County Medical Center, Inc.

Details

Name: Tri-County Medical Center, Inc.
Jurisdiction: Alabama
Legal type: Domestic Non-Profit Corporation
Status: Exists
Date of registration: 21 Oct 1991 (33 years ago)
Entity Number: 000-069-761
Register Number: 000069761
ZIP code: 36401
County: Conecuh
Place of Formation: Conecuh County
Principal Address: EVERGREEN, AL
Registered Office Street Address: 315 LIBERTY HILL DRIVEEVERGREEN, AL 36401

Activities PRIMARY CARE HEALTH PROGRAM

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1740430107 2008-09-23 2008-09-24 PO BOX 726, EVERGREEN, AL, 364010726, US COUNTY ROAD 49, LOWER PEACH TREE, AL, 36751, US

Contacts
Phone +1 251-578-1163
Fax 2515786963
Phone +1 334-636-2925

Authorized person
Name MARILYN J SAWYER
Role EXECUTIVE DIRECTOR
Phone 2515781163

Taxonomy
Taxonomy Code 261QF0400X - Federally Qualified Health Center (FQHC)
Is Primary Yes

Other Provider Identifiers
Issuer CLIA NUMBER
Number 01D0867799
State AL

Commercial and government entity program

CAGE number Status Type Established CAGE Update Date CAGE Expiration SAM Expiration
3SHP0 Active Non-Manufacturer 2004-03-16 2014-08-26 No data No data

Contact Information
POC DEBORAH HOFFMAN
Phone +1 251-578-1163
Fax +1 251-578-6963
Address 316 S MAIN ST, EVERGREEN, AL, 36401 3313, UNITED STATES

Ownership of Offeror Information
Highest Level Owner Information not Available
Immediate Level Owner Information not Available
List of Offerors (0) Information not Available

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
TRI COUNTY MEDICAL CENTER, INC. 403(B) PLAN 2014 631056564 2017-02-23 TRI COUNTY MEDICAL CENTER, INC. 50
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2009-12-01
Business code 622000
Sponsor’s telephone number 3344530777
Plan sponsor’s address PO BOX 726, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2017-02-23
Name of individual signing GREG GRIFFIN
TRI COUNTY MEDICAL CENTER, INC. 403(B) PLAN 2014 631056564 2016-02-18 TRI COUNTY MEDICAL CENTER, INC. 50
Three-digit plan number (PN) 002
Effective date of plan 2009-12-01
Business code 622000
Sponsor’s telephone number 3344530777
Plan sponsor’s address PO BOX 726, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2016-02-18
Name of individual signing GREG GRIFFIN
TRI COUNTY MEDICAL CENTER, INC. 403(B) PLAN 2013 631056564 2016-01-04 TRI COUNTY MEDICAL CENTER, INC. 41
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2009-12-01
Business code 622000
Sponsor’s telephone number 2515781163
Plan sponsor’s address PO BOX 726, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2016-01-04
Name of individual signing GREG GRIFFIN
TRI COUNTY MEDICAL CENTER INC 401 K PROFIT SHARING PLAN TRUST 2013 631056564 2014-10-15 TRI COUNTY MEDICAL CENTER INC 46
File View Page
Three-digit plan number (PN) 003
Effective date of plan 2013-01-01
Business code 621111
Sponsor’s telephone number 2515781163
Plan sponsor’s address 316 S MAIN ST, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2014-10-15
Name of individual signing TRI COUNTY MEDICAL CENTER INC
TRI-COUNTY MEDICAL CENTER, INC. PROFIT SHARING PLAN AND TRUST 2012 631056564 2014-07-28 TRI-COUNTY MEDICAL CENTER, INC. 49
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-12-01
Business code 621111
Sponsor’s telephone number 2515781163
Plan sponsor’s address 316 SOUTH MAIN STREET, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2014-07-28
Name of individual signing GREG GRIFFIN
TRI COUNTY MEDICAL CENTER, INC. 403(B) PLAN 2012 631056564 2014-05-13 TRI COUNTY MEDICAL CENTER, INC. 50
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2009-12-01
Business code 622000
Sponsor’s telephone number 2515781163
Plan sponsor’s address 316 SOUTH MAIN STREET, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2014-05-13
Name of individual signing GREG GRIFFIN
TRI-COUNTY MEDICAL CENTER, INC. PROFIT SHARING PLAN AND TRUST 2011 631056564 2013-11-14 TRI-COUNTY MEDICAL CENTER, INC. 43
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1991-12-01
Business code 621111
Sponsor’s telephone number 2515781163
Plan sponsor’s address 316 SOUTH MAIN STREET, EVERGREEN, AL, 36401

Plan administrator’s name and address
Administrator’s EIN 631056564
Plan administrator’s name SAME
Plan administrator’s address 316 SOUTH MAIN STREET, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2013-11-14
Name of individual signing GREG GRIFFIN
TRI-COUNTY MEDICAL CENTER, INC. PROFIT SHARING PLAN AND TRUST 2011 631056564 2013-10-30 TRI-COUNTY MEDICAL CENTER, INC. 43
Three-digit plan number (PN) 001
Effective date of plan 1991-12-01
Business code 621111
Sponsor’s telephone number 2515781163
Plan sponsor’s address 316 SOUTH MAIN STREET, EVERGREEN, AL, 36401

Plan administrator’s name and address
Plan administrator’s name SAME
Plan administrator’s address 316 SOUTH MAIN STREET, EVERGREEN, AL, 36401

Signature of
Role Plan administrator
Date 2013-10-21
Name of individual signing GREG GRIFFIN

Incorporator

Name Role Address
SULLIVAN, TERRY Incorporator 2309 QUEENSVIEW RDHOOVER, AL
DANNELLY, SARAH Incorporator No data
BAGGETT, LAURICE Incorporator No data
WILSON, MARY SUE Incorporator No data
HART, BILL Incorporator 5137 CANDLE BROOK TERRACEBESSEMER, AL 35022
INGRAM, ARTHUR Incorporator No data
MCGUFFEE, REV WOODSON Incorporator No data
MAXWELL, GERALDINE Incorporator No data
CROSBY, MYRTLE Incorporator No data
THOMAS, ALMA Incorporator 316 ELM ST APT 22-AANNISTON, AL 36201

Agent

Name Role Address
HART, BILL Agent 5137 CANDLE BROOK TERRACEBESSEMER, AL 35022

Related by officers

SULLIVAN, TERRY

A&T Woodworks L.L.C. SULLIVAN GLOBAL GROUP, LLC Kerri Lane Estates, Inc., a close corporation BCM, L.L.C. TSU, L.L.C.

HART, BILL

Bill Hart and Associates, LLC Conecuh County Emergency Medical Services Committee Incorporated Candlebrook Homeowners' Association, Inc. Conecuh Volunteer County Rescue/Fire Squad, Inc.

THOMAS, ALMA

AGAPE MILLENIUM INTERNATIONAL, INC. Lakewood Homes, Inc.

Related by address

EVERGREEN, AL

Allen Oil Company, Inc. B & S Drugs, Inc. Bank of Evergreen Beaven-Jackson Lumber & Veneer Company Conecuh Co-operative Stockyard Connie Manufacturing Company Cotton-Hutcheson, Inc. Evergreen Club The Evergreen Courant, Inc. Witherington Farms, Inc.

Date of last update: 31 Jul 2024

Sources: Alabama Secretary of State

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