Covered Entity Details

DSH010024AF JACKSON HOSPITAL AND CLINIC INC (Active) - information as of 5/6/2025 11:14:46 PM

Main Details

Name

JACKSON HOSPITAL AND CLINIC INC

Subdivision Name

Jackson Hospital Family Medicine Residency Program - Family Medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH010024AF

Medicare Provider Number

010024

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2025

Participating Start Date

4/1/2025

Participating Approval Date

3/10/2025

Last Recertification Date

Contacts

Authorizing Official

Jackson Hospital and Clinics
Thomas Hudson Cobb, Director of Pharmacy
(334) 293-8806

Primary Contact

Jackson Hospital & Clinic, Inc.
Ashley Cherie Forbus, 340B Program Manager
(334) 293-8788

Addresses

Street Address

2024 Chestnut Street
Montgomery, AL 36106

Billing Address

Jackson Hospital & Clinic, Inc.
1725 Pine Street
Montgomery, AL 36106

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
AL	HOS0024H	1043262488

Shipping Addresses

Shipping Address 1

Jackson Hospital & Clinic, Inc.
1725 Pine Street
Montgomery, AL 36106

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH010024A	Child	DSH	JACKSON HOSPITAL AND CLINIC, INC.	JACKSON IMAGING CENTER, LLC	1825 PARK PLACE	MONTGOMERY	AL	Terminated
DSH010024AA	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic JFM Pine Level - Family Medicine	2175 us hwy 31 N	Deatsville	AL	Active
DSH010024AB	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Infectious Disease - Infectious Disease	1722 pine street	Montgomery	AL	Active
DSH010024AC	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Mora Surgical - General surgical	554 McQueen Smith Road North	Prattville	AL	Active
DSH010024AD	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Pike Rd Urgent Care - Urgent Care	9521 vaughn Road	Pike Road	AL	Active
DSH010024AE	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic - Prim Care - Internal Medicine	1722 Pine Street	Montgomery	AL	Active
DSH010024AF	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Hospital Family Medicine Residency Program - Family Medicine	2024 Chestnut Street	Montgomery	AL	Active
DSH010024B	Child	DSH	JACKSON HOSPITAL AND CLINIC, INC.	JACKSON HOSPITAL SLEEP DISORDERS CLINIC	1722 PINE STREET SUITE 900	MONTGOMERY	AL	Terminated
DSH010024C	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON HOSPITAL WOUND CARE CENTER	1801 PINE STREET SUITE 101	MONTGOMERY	AL	Active
DSH010024D	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC DALRAIDA - Family Medicine	4035 ATLANTA HWY	MONTGOMERY	AL	Active
DSH010024E	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON OBSTETRICS & GYNECOLOGY - OBSTETRICS & GYNECOLOGY	1758 Park Place	Montgomery	AL	Active
DSH010024F	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Endocrinology - Endocrinology	1801 Pine Street	Montgomery	AL	Active
DSH010024G	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic- General Surgery - General Surgery	1722 Pine St.	Montgomery	AL	Active
DSH010024H	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON FAMILY MED MIDTOWN - Family Medicine	4150 CARMICHAEL RD	MONTGOMERY	AL	Active
DSH010024J	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Urology East - Urology	226 MITYLENE PARK DR	Montgomery	AL	Terminated
DSH010024K	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON FAMILY MEDICINE PRATTVILLE - Family Medicine	701 MCQUEEN SMITH RD S	PRATTVILLE	AL	Active
DSH010024L	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Urology - Urology	1722 Pine Street	Montgomery	AL	Active
DSH010024M	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Internal Medicine - Internal Medicine	1801 Pine Street	Montgomery	AL	Active
DSH010024N	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC GASTROENTEROLOGY - Gastroenterology	1722 PINE ST	MONTGOMERY	AL	Active
DSH010024P	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Family Medicine - Family Medicine	1801 Pine Street	Montgomery	AL	Active
DSH010024Q	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON HOSP & CLINIC PK RD - Family Medicine	11123 CHANTILLY PKWY CT	PIKE ROAD	AL	Terminated
DSH010024R	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Dr. Seirafi - General Surgery	7201 Copperfield Drive	Montgomery	AL	Terminated
DSH010024S	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Neurology - Neurology	1722 Pine St	Montgomery	AL	Active
DSH010024T	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC VASCULAR SURGERY - Vascular Surgery	1758 PARK PLACE	MONTGOMERY	AL	Active
DSH010024U	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	Jackson Cardiology - Cardiology	1758 Park Place	Montgomery	AL	Active
DSH010024V	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC MULTI SPECIALTY PRAT - Specialty Medicine Services	1840 E MAIN ST	PRATTVILLE	AL	Active
DSH010024W	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON SLEEP DISORDERS CENTER - Sleep Studies	1722 PINE ST	MONTGOMERY	AL	Active
DSH010024X	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC PRATTVILLE PRIMARY C - Primary Care	204 MEDICAL CENTER DR	PRATTVILLE	AL	Active
DSH010024Y	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	OP Infusion Clinic - Infusion Services	1725 Pine Street	Montgomery	AL	Active
DSH010024Z	Child	DSH	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC RHEUMATOLOGY - Rheumatology	1722 PINE STREET	MONTGOMERY	AL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Cobb, Thomas Hudson Director of Pharmacy Jackson Hospital and Clinics 3342938806	3/10/2025 2:55 PM
Details	340B ID	Update	New Registration		DSH010024AF	3/10/2025 2:55 PM
Details	Entity Subname	Update	New Registration	Jackson Hospital Family Medicine Residency Program	Jackson Hospital Family Medicine Residency Program - Family Medicine	3/10/2025 2:55 PM
Dates	Participating Approval Date	Update	New Registration		3/10/2025 2:55:28 PM	3/10/2025 2:55 PM
Details	State	Update	New Registration	Pending	Approved	3/10/2025 2:55 PM
Dates	Signed By Date	Update	New Registration		3/10/2025 2:04:10 PM	3/10/2025 2:55 PM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	3/10/2025 2:55 PM
Addresses	Main Address	Insert	New Registration		2024 Chestnut Street Montgomery, AL 36106	1/15/2025 10:59 AM
Addresses	Billing Address	Insert	New Registration		Jackson Hospital & Clinic, Inc. 1725 Pine Street Montgomery, AL 36106	1/15/2025 10:59 AM
Addresses	Shipping Address	Insert	New Registration		Jackson Hospital & Clinic, Inc. 1725 Pine Street Montgomery, AL 36106	1/15/2025 10:59 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2025 10:59 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HOS0024H	1/15/2025 10:59 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	1/15/2025 10:59 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043262488	1/15/2025 10:59 AM
Medicaid Billing	NPI: State	Insert	New Registration		AL	1/15/2025 10:59 AM
Contacts	Authorizing Official	Insert	New Registration		Cobb, Thomas Hudson Director of Pharmacy Jackson Hospital and Clinics 3342938806	1/15/2025 10:59 AM
Contacts	Primary Contact	Insert	New Registration		Forbus, Ashley Cherie 340B Program Manager Jackson Hospital & Clinic, Inc. 3342938788	1/15/2025 10:59 AM
Details	Assistance Received From Date	Insert	New Registration			1/15/2025 10:59 AM
Details	Assistance Received To Date	Insert	New Registration			1/15/2025 10:59 AM
Details	Last Recertification Date	Insert	New Registration			1/15/2025 10:59 AM
Details	Grant Number	Insert	New Registration			1/15/2025 10:59 AM
Details	340B ID	Insert	New Registration			1/15/2025 10:59 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2025 10:59 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2025 10:59 AM
Details	Medicare Provider Number	Insert	New Registration		010024	1/15/2025 10:59 AM
Details	Entity Name	Insert	New Registration		JACKSON HOSPITAL AND CLINIC INC	1/15/2025 10:59 AM
Details	NOFO Number	Insert	New Registration			1/15/2025 10:59 AM
Details	Program Code	Insert	New Registration		DSH	1/15/2025 10:59 AM
Details	Entity Subname	Insert	New Registration		Jackson Hospital Family Medicine Residency Program	1/15/2025 10:59 AM
Dates	Participating Approval Date	Insert	New Registration			1/15/2025 10:59 AM
Details	State	Insert	New Registration		Pending	1/15/2025 10:59 AM
Dates	Registration Date	Insert	New Registration		1/15/2025 10:59:39 AM	1/15/2025 10:59 AM
Dates	Signed By Date	Insert	New Registration			1/15/2025 10:59 AM
Dates	Start Date	Insert	New Registration			1/15/2025 10:59 AM
Terminations	Termination Comments	Insert	New Registration			1/15/2025 10:59 AM
Terminations	Termination Date	Insert	New Registration			1/15/2025 10:59 AM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2025 10:59 AM
Terminations	Termination Reason	Insert	New Registration			1/15/2025 10:59 AM