Covered Entity Details

DSH250006E BAPTIST MEMORIAL HOSPITAL - UNION COUNTY (Approved) - information as of 5/27/2025 11:34:28 PM

Main Details

Name

BAPTIST MEMORIAL HOSPITAL - UNION COUNTY

Subdivision Name

Baptist Union County Cancer Center Booneville - clinic, oncology and infusion

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH250006E

Medicare Provider Number

250006

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/11/2025

Last Recertification Date

Contacts

Authorizing Official

Baptist Memorial Health Care Corporation
Cyndi Pittman, VP Financial Operations
(901) 227-8480

Primary Contact

Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144

Addresses

Street Address

100 Hospital Dr.
Booneville, MS 38829

Billing Address
Same as Street Address

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
MS	00020010	1780648352

Shipping Addresses

Same as Street Address

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
DSH250006A	Child	DSH	BAPTIST MEMORIAL HOSPITAL - UNION COUNTY	BAPTIST CANCER CENTER - Oncology and Infusion	1300 SUNSET DR	GRENADA	MS	Active
DSH250006B	Child	DSH	BAPTIST MEMORIAL HOSPITAL - UNION COUNTY	BAPTIST CANCER CENTER - Oncology and Infusion	504 AZALEA DR	OXFORD	MS	Active
DSH250006C	Child	DSH	BAPTIST MEMORIAL HOSPITAL - UNION COUNTY	BAPTIST RHEUMATOLOGY - Rheumatology	100 BAPTIST MEMORIAL CIR	OXFORD	MS	Active
DSH250006D	Child	DSH	BAPTIST MEMORIAL HOSPITAL - UNION COUNTY	Baptist Memorial Hospital Union County Cancer Center - Oncology	363 Southcrest Cir	Southaven	MS	Active
DSH250006E	Child	DSH	BAPTIST MEMORIAL HOSPITAL - UNION COUNTY	Baptist Union County Cancer Center Booneville - clinic, oncology and infusion	100 Hospital Dr.	Booneville	MS	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Pittman, Cyndi VP Financial Operations Baptist Memorial Health Care Corporation 9012278480	4/11/2025 12:49 PM
Details	340B ID	Update	New Registration		DSH250006E	4/11/2025 12:49 PM
Details	Entity Name	Update	New Registration	BAPTIST MEM HOSPITAL UNION COUNTY	BAPTIST MEMORIAL HOSPITAL - UNION COUNTY	4/11/2025 12:49 PM
Details	Entity Subname	Update	New Registration	Baptist Union County Cancer Center Booneville	Baptist Union County Cancer Center Booneville - clinic, oncology and infusion	4/11/2025 12:49 PM
Dates	Participating Approval Date	Update	New Registration		4/11/2025 12:49:49 PM	4/11/2025 12:49 PM
Details	State	Update	New Registration	Pending	Approved	4/11/2025 12:49 PM
Dates	Signed By Date	Update	New Registration		4/8/2025 3:13:01 PM	4/11/2025 12:49 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/11/2025 12:49 PM
Addresses	Main Address	Insert	New Registration		100 Hospital Dr. Booneville, MS 38829	4/1/2025 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 3:28 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00020010	4/1/2025 3:28 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	4/1/2025 3:28 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1780648352	4/1/2025 3:28 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	4/1/2025 3:28 PM
Contacts	Authorizing Official	Insert	New Registration		Pittman, Cyndi VP Financial Operations Baptist Memorial Health Care Corporation 9012278480	4/1/2025 3:28 PM
Contacts	Primary Contact	Insert	New Registration		Cox, Donna C Director 340B Baptist Memorial Health Care Corp 9012275144	4/1/2025 3:28 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 3:28 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 3:28 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 3:28 PM
Details	Grant Number	Insert	New Registration			4/1/2025 3:28 PM
Details	340B ID	Insert	New Registration			4/1/2025 3:28 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 3:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 3:28 PM
Details	Medicare Provider Number	Insert	New Registration		250006	4/1/2025 3:28 PM
Details	Entity Name	Insert	New Registration		BAPTIST MEM HOSPITAL UNION COUNTY	4/1/2025 3:28 PM
Details	NOFO Number	Insert	New Registration			4/1/2025 3:28 PM
Details	Program Code	Insert	New Registration		DSH	4/1/2025 3:28 PM
Details	Entity Subname	Insert	New Registration		Baptist Union County Cancer Center Booneville	4/1/2025 3:28 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 3:28 PM
Details	State	Insert	New Registration		Pending	4/1/2025 3:28 PM
Dates	Registration Date	Insert	New Registration		4/1/2025 3:28:53 PM	4/1/2025 3:28 PM
Dates	Signed By Date	Insert	New Registration			4/1/2025 3:28 PM
Dates	Start Date	Insert	New Registration			4/1/2025 3:28 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 3:28 PM
Terminations	Termination Date	Insert	New Registration			4/1/2025 3:28 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 3:28 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 3:28 PM