Covered Entity Details

DSH260070 PEMISCOT COUNTY MEMORIAL HOSPITAL (Active) - information as of 5/30/2025 8:14:17 PM

Main Details

Name

PEMISCOT COUNTY MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260070

Medicare Provider Number

260070

Additional Details

Current Program Status

Active

Registration Date

10/3/2014

Participating Start Date

1/1/2015

Participating Approval Date

12/12/2014

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Pemiscot Memorial Health Systems
DAVID KETCHUM, CEO
(573) 359-3579

Primary Contact

PEMISCOT MEMORIAL HEALTH SYSTEMS
Loren Clifton, Pharmacy Technican
(573) 359-3612

Addresses

Street Address

946 East Reed
HAYTI, MO 63851

Billing Address

Pemiscot County Memorial Hospital
946 East Reed
Hayti, MO 63851

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
11/3/14;CE reinstated effective 1/1/15; was participating from 4/1/2008 to 9/30/13; not participating from 10/1/2013 to 12/30/14 due to failure to recertify.	12/12/2014

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
MO	010988509	1437179710
AR	108746105	1437179710

Shipping Addresses

Shipping Address 1

Pemiscot County Memorial Hospital
946 East Reed
Hayti, MO 63851

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ALLCARE SPECIALTY PHARMACY, LLC	10620 COLONEL GLENN RD STE 300		LITTLE ROCK	AR	72204-8048	10/10/2017	01/01/2018	11/01/2022	11/21/2022
Contract Detail	CORNERSTONE PHARMACY KENNETT, LLC	CORNERSTONE PHARMACY	123 1ST ST	KENNETT	MO	63857-2051	07/15/2024	10/01/2024		10/01/2024
Contract Detail	GREENE PHARMACY	CITY OF STEELE GREENE PHAR,INC	128 W MAIN ST	STEELE	MO	63877-1434	01/20/2015	04/01/2015	03/01/2022	03/08/2022
Contract Detail	HARRIS PHARMACY	1224 1ST ST		KENNETT	MO	63857-2528	01/20/2015	04/01/2015		01/20/2015
Contract Detail	HAYDEN'S PHARMACY	ECB PHARMACY INC	1200 WARD AVE	CARUTHERSVILLE	MO	63830	01/04/2018	04/01/2018	09/30/2019	04/03/2020
Contract Detail	HAYDEN'S PHARMACY	ECB PHARMACY INC	1200 WARD AVE	CARUTHERSVILLE	MO	63830	07/03/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM INFUSION SERVICES 500, INC.	4900 RIVERGRADE RD STE E120		IRWINDALE	CA	91706-1419	07/06/2021	10/01/2021	08/02/2022	08/02/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/15/2021	07/01/2021	11/01/2022	11/21/2022
Contract Detail	OPTUM PHARMACY 801, INC.	23620 N 20TH DR STE 12		PHOENIX	AZ	85085-0621	04/15/2021	07/01/2021	11/01/2022	11/21/2022
Contract Detail	PRESCRIPTION DRUG STORE LLC	PRESCRIPTION DRUG STORE #1	410 WARD AVE	CARUTHERSVILLE	MO	63830	04/15/2016	07/01/2016	08/20/2019	08/29/2019
Contract Detail	PRESCRIPTION DRUG STORE LLC	PRESCRIPTION DRUG STORE #2	308 EAST MAIN	HAYTI	MO	63851	04/15/2016	07/01/2016	08/20/2019	08/29/2019
Contract Detail	PRESCRIPTION DRUG STORE LLC	PRESCRIPTION DRUG STORE #2	308 EAST MAIN	HAYTI	MO	63851	04/03/2020	07/01/2020		07/01/2020
Contract Detail	PRESCRIPTION DRUG STORE LLC	PRESCRIPTION DRUG STORE #1	410 WARD AVE	CARUTHERSVILLE	MO	63830	04/03/2020	07/01/2020		07/01/2020
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/01/2024	07/01/2024		07/01/2024
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/01/2024	07/01/2024		07/01/2024
Contract Detail	TEKO PHARMACY	501 TEACO RD		KENNETT	MO	63857-3721	04/15/2016	07/01/2016	06/30/2024	07/03/2024
Contract Detail	TRAINOR-CLEVENGER DRUG STORE	TRAINOR-CLEVENGER DRUG STORE	225 S 3RD ST	HAYTI	MO	63851	01/20/2015	04/01/2015	02/21/2018	08/29/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/16/2017	04/01/2017		01/16/2017
Contract Detail	WAL-MART PHARMACY 10-0009	1303 S MAIN ST		SIKESTON	MO	63801	01/09/2017	04/01/2017		01/09/2017
Contract Detail	WAL-MART PHARMACY 10-0062	3700 EAST HIGHWAY 18		BLYTHEVILLE	AR	72315	01/09/2017	04/01/2017		01/09/2017
Contract Detail	WAL-MART PHARMACY 10-0156		STATE HWY 84 WEST PO BOX 971	CARUTHERSVILLE	MO	63830	01/20/2015	04/01/2015	02/08/2017	02/09/2017
Contract Detail	WAL-MART PHARMACY 10-0190	1500 E FIRST ST		KENNETT	MO	63857	01/20/2015	04/01/2015		01/20/2015
Contract Detail	WAL-MART PHARMACY 10-0677	2650 LAKE ROAD		DYERSBURG	TN	38024	01/09/2017	04/01/2017		01/09/2017
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/16/2017	04/01/2017		01/16/2017
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/09/2023	04/01/2023		04/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH260070A	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Pemiscot Primary Care (Hayti Clinic)	907 East Reed	Hayti	MO	Active
DSH260070B	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Doctors Clinic	106 W 12TH ST	CARUTHERSVILLE	MO	Active
DSH260070C	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Portageville Primary Care	314 East Main	Portageville	MO	Terminated
DSH260070D	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Pemiscot Primary Care Clinic - Kennett	1231 First Street	Kennett	MO	Active
DSH260070E	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	PMHS Convenient Care	946 East Reed	Hayti	MO	Active
DSH260070F	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	BOOTHEEL PRIMARY CARE CLINIC-STEELE	213 SOUTH WALNUT STREET	STEELE	MO	Active
DSH260070G	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Bootheel Primary Care - New Madrid	555 Virginia Avenue	New Madrid	MO	Terminated
DSH260070H	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Bootheel Primary Care - Caruthersville	1502 Ward Avenue	Caruthersville	MO	Active
DSH260070J	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Physicians Diagnostic Center - Advanced Diagnostic Center	225 North Hwy J	Hayti	MO	Active
DSH260070K	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Pain Management - Injection Clinic	225 North Hwy J	Hayti	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 7:37:59 AM	8/20/2024 10:00:17 AM	8/20/2024 10:00 AM
Contacts	Primary Contact	Update	Group Change Request	Cooper, Rosie 340B Pharmacy Technician Pemiscot Memorial Health Systems 5732596174	Clifton, Loren Pharmacy Technican PEMISCOT MEMORIAL HEALTH SYSTEMS 5733593612	4/1/2024 8:44 AM
Contacts	Authorizing Official	Update	Profile Change Request	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	KETCHUM, DAVID CEO Pemiscot Memorial Health Systems 5733593579	4/1/2024 8:43 AM
Contacts	Primary Contact	Update	Group Change Request	Carpenter, Tammy 340B CPhT Pemiscot County Memorial Hospital 5733593454	Cooper, Rosie 340B Pharmacy Technician Pemiscot Memorial Health Systems 5732596174	11/27/2023 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 6:45:25 PM	8/15/2023 7:37:59 AM	8/15/2023 7:37 AM
Contacts	Authorizing Official	Update	Change Request	Ward, Leigha Kristen Chief Financial Officer Pemiscot County Memorial Hospital 5733593612	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	1/9/2023 7:46 AM
Contacts	Primary Contact	Update	Change Request	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	Carpenter, Tammy 340B CPhT Pemiscot County Memorial Hospital 5733593454	1/4/2023 6:47 AM
Details	Last Recertification Date	Update	Recertification	8/30/2021 9:52:49 AM	8/29/2022 6:45:25 PM	8/29/2022 6:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010988509	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		108746105	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	9/13/2021 1:27 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437179710	9/13/2021 1:27 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	9/13/2021 1:27 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437179710	9/13/2021 1:27 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	9/13/2021 1:27 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 10:24:34 AM	8/30/2021 9:52:49 AM	8/30/2021 9:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	108746105 (AR)		6/14/2021 4:13 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010988509 (MO)		6/14/2021 4:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437179710 (MO)		6/14/2021 4:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437179710 (AR)		6/14/2021 4:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2020 5:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		108746105	11/12/2020 5:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	11/12/2020 5:53 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437179710	11/12/2020 5:53 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	11/12/2020 5:53 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1437179710	8/18/2020 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/18/2020 10:24 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1437179710 ( )		8/18/2020 10:24 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 11:55:07 AM	8/18/2020 10:24:34 AM	8/18/2020 10:24 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 3:27:07 PM	9/5/2019 11:55:07 AM	9/5/2019 11:55 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 9:51:14 PM	8/22/2018 3:27:07 PM	8/22/2018 3:27 PM
Contacts	Authorizing Official	Update	Change Request	Marshall, Jim CEO Pemiscot Memorial Health Systems 5733593612	Ward, Leigha Kristen Chief Financial Officer Pemiscot County Memorial Hospital 5733593612	7/11/2018 2:45 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/15/2017 9:51:14 PM	11/15/2017 9:51 PM
Contacts	Authorizing Official	Insert	Change Request		Marshall, Jim CEO Pemiscot Memorial Health Systems 5733593612	9/28/2017 10:51 AM
Contacts	Primary Contact	Update		KETCHUM, DAVID DIRECTOR OF PHARMACY 5733593579	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	9/26/2017 11:12 AM
Contacts	Signed By	Insert			NOBLE, KERRY L. CEO 5733593612	2/9/2017 11:13 AM
Addresses	Main Address	Insert			946 East Reed HAYTI, MO 63851	8/31/2016 10:23 AM
Contacts	Primary Contact	Insert			KETCHUM, DAVID DIRECTOR OF PHARMACY 5733593579	8/31/2016 10:23 AM
Details	Last Recertification Date	Update		8/21/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 10:23 AM
Details	Last Recertification Date	Update			8/21/2015 12:00:00 AM	8/24/2015 10:41 AM
Addresses	Billing Address	Insert			Pemiscot County Memorial Hospital 946 East Reed Hayti, MO 63851	4/27/2015 3:54 PM
Addresses	Shipping Address	Insert			Pemiscot County Memorial Hospital 946 East Reed Hayti, MO 63851	4/27/2015 3:54 PM
Details	340B ID	Update		DSH260070.	DSH260070	12/12/2014 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/12/2014 9:55 AM
Medicaid Billing	Medicaid: Number	Insert			010988509	12/12/2014 9:55 AM
Medicaid Billing	Medicaid: State	Insert			MO	12/12/2014 9:55 AM
Medicaid Billing	NPI: Number	Insert			1437179710	12/12/2014 9:55 AM
Details	Last Recertification Date	Update		9/14/2013 12:00:00 AM		12/12/2014 9:55 AM
Details	340B ID	Update		DSH260070	DSH260070.	12/12/2014 9:55 AM
Dates	Last Date That 340B Drugs Purchased	Update		10/1/2013 12:00:00 AM		12/12/2014 9:55 AM
Details	Entity Name	Update		PEMISCOT MEMORIAL HOSPITAL	PEMISCOT COUNTY MEMORIAL HOSPITAL	12/12/2014 9:55 AM
Dates	Participating Approval Date	Update		3/4/2008 12:00:00 AM	12/12/2014 12:00:00 AM	12/12/2014 9:55 AM
Details	State	Update		Terminated	Active	12/12/2014 9:55 AM
Dates	Registration Date	Update		3/4/2008 12:00:00 AM	10/3/2014 12:00:00 AM	12/12/2014 9:55 AM
Dates	Signed By Date	Update		1/30/2008 12:00:00 AM	10/3/2014 12:00:00 AM	12/12/2014 9:55 AM
Dates	Start Date	Update		4/1/2008 12:00:00 AM	1/1/2015 12:00:00 AM	12/12/2014 9:55 AM
Terminations	Termination Date	Update		10/1/2013 12:00:00 AM		12/12/2014 9:55 AM
Terminations	Termination Effective Date	Update		10/1/2013 12:00:00 AM		12/12/2014 9:55 AM
Terminations	Termination Reason	Update		Failure to recertify		12/12/2014 9:55 AM
Details	Comments Public	Insert			11/3/14;CE reinstated effective 1/1/15; was participating from 4/1/2008 to 9/30/13; not participating from 10/1/2013 to 12/30/14 due to failure to recertify.	12/12/2014 9:55 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/14/2013 12:00:00 AM	9/14/2013 7:30 AM
Dates	Last Date That 340B Drugs Purchased	Update			10/1/2013 12:00:00 AM	9/14/2013 7:30 AM
Details	State	Update		Active	Terminated	9/14/2013 7:30 AM
Terminations	Termination Date	Update			10/1/2013 12:00:00 AM	9/14/2013 7:30 AM
Terminations	Termination Effective Date	Update			10/1/2013 12:00:00 AM	9/14/2013 7:30 AM
Terminations	Termination Reason	Update			Failure to recertify	9/14/2013 7:30 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/30/2012 7:31 AM
Details	Last Recertification Date	Insert				3/4/2008 2:17 PM
Details	Grant Number	Insert				3/4/2008 2:17 PM
Details	340B ID	Insert			DSH260070	3/4/2008 2:17 PM
Details	Is Authorizing Official EHB Data	Insert				3/4/2008 2:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert				3/4/2008 2:17 PM
Details	Medicare Provider Number	Insert			260070	3/4/2008 2:17 PM
Details	Entity Name	Insert			PEMISCOT MEMORIAL HOSPITAL	3/4/2008 2:17 PM
Details	Program Code	Insert			DSH	3/4/2008 2:17 PM
Details	Entity Subname	Insert				3/4/2008 2:17 PM
Dates	Participating Approval Date	Insert			3/4/2008 12:00:00 AM	3/4/2008 2:17 PM
Details	State	Insert			Active	3/4/2008 2:17 PM
Dates	Registration Date	Insert			3/4/2008 12:00:00 AM	3/4/2008 2:17 PM
Dates	Signed By Date	Insert			1/30/2008 12:00:00 AM	3/4/2008 2:17 PM
Dates	Start Date	Insert			4/1/2008 12:00:00 AM	3/4/2008 2:17 PM
Terminations	Termination Comments	Insert				3/4/2008 2:17 PM
Terminations	Termination Date	Insert				3/4/2008 2:17 PM
Terminations	Termination Effective Date	Insert				3/4/2008 2:17 PM
Terminations	Termination Reason	Insert				3/4/2008 2:17 PM