Covered Entity Details

DSH250077A WAYNE GENERAL HOSPITAL (Active) - information as of 6/3/2025 10:56:48 AM

Main Details

Name

WAYNE GENERAL HOSPITAL

Subdivision Name

WAYNE GENERAL HOSPICE

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH250077A

Medicare Provider Number

250077

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

3/17/2010

Participating Start Date

4/1/2010

Participating Approval Date

3/17/2010

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Wayne General Hospital
Andrew Porter, CEO
(601) 735-5151 Ext: 100

Primary Contact

Wayne General Hospital
Clinton Eaves, CFO
(601) 735-7103

Addresses

Street Address

951 MATTHEW DRIVE
WAYNESBORO, MS 39367

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	00770036	1215958780

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
DSH250077A	Child	DSH	WAYNE GENERAL HOSPITAL	WAYNE GENERAL HOSPICE	951 MATTHEW DRIVE	WAYNESBORO	MS	Active
DSH250077B	Child	DSH	WAYNE GENERAL HOSPITAL	ARTHUR E. WOOD MEDICAL CLINIC	951 MATTHEW DRIVE	WAYNESBORO	MS	Active
DSH250077C	Child	DSH	WAYNE GENERAL HOSPITAL	WAYNESBORO FAMILY MEDICINE AND OBSTETRICS	951 MATTHEW DRIVE	WAYNESBORO	MS	Active
DSH250077D	Child	DSH	WAYNE GENERAL HOSPITAL	WAYNE GENERAL HOSPITAL - Wayne General School Clinic	1325 AZALEA DR	WAYNESBORO	MS	Active
DSH250077E	Child	DSH	WAYNE GENERAL HOSPITAL	Infusion Clinic - Infusion	940 Matthew Drive	Waynesboro	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Anderson, Linda CFO Wayne General Hospital 6017357103	Eaves, Clinton CFO Wayne General Hospital 6017357103	1/8/2025 12:30 PM
Details	Last Recertification Date	Update	Recertification	8/21/2023 11:13:29 AM	8/13/2024 11:24:33 AM	8/13/2024 11:24 AM
Contacts	Authorizing Official	Update	AO Change Request	Waddell, Kathy CEO Wayne General Hospital 6017355151-100	Porter, Andrew CEO Wayne General Hospital 6017355151-100	10/16/2023 11:08 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 2:26:16 PM	8/21/2023 11:13:29 AM	8/21/2023 11:13 AM
Details	Last Recertification Date	Update	Recertification	8/31/2021 2:11:07 PM	8/24/2022 2:26:16 PM	8/24/2022 2:26 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 1:02:46 PM	8/31/2021 2:11:07 PM	8/31/2021 2:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1215958780	8/28/2020 1:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/28/2020 1:02 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1215958780 ( )		8/28/2020 1:02 PM
Details	Last Recertification Date	Update	Recertification	9/2/2019 3:42:48 PM	8/28/2020 1:02:46 PM	8/28/2020 1:02 PM
Contacts	Primary Contact	Update	Recertification	Kelly, Sheri Accountant Wayne General Hospital 6017357100	Anderson, Linda CFO Wayne General Hospital 6017357103	9/2/2019 3:42 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 11:36:39 AM	9/2/2019 3:42:48 PM	9/2/2019 3:42 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 10:41:34 AM	8/16/2018 11:36:39 AM	8/16/2018 11:36 AM
Contacts	Primary Contact	Update	Recertification	Waddell, Kathy CEO 6017355151-100	Kelly, Sheri Accountant Wayne General Hospital 6017357100	11/3/2017 10:41 AM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/3/2017 10:41:34 AM	11/3/2017 10:41 AM
Contacts	Authorizing Official	Update		Waddell, Kathy CEO 6017355151-100	Waddell, Kathy CEO Wayne General Hospital 6017355151-100	10/11/2017 9:50 AM
Addresses	Main Address	Insert			951 MATTHEW DRIVE WAYNESBORO, MS 39367	4/11/2017 2:26 PM
Contacts	Authorizing Official	Update		Waddell, Kathy CEO 6017355151-100	Waddell, Kathy CEO 6017355151-100	4/11/2017 2:26 PM
Contacts	Primary Contact	Insert			Waddell, Kathy CEO 6017355151-100	4/11/2017 2:26 PM
Medicaid Billing	NPI: Number	Insert			1215958780	3/20/2017 4:38 PM
Details	Last Recertification Date	Update		8/12/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 5:42 PM
Contacts	Authorizing Official	Insert			Waddell, Kathy CEO 6017355151-100	8/12/2015 3:29 PM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/12/2015 12:00:00 AM	8/12/2015 3:29 PM
Details	Last Recertification Date	Update		9/6/2013 3:47:17 PM	8/28/2014 12:00:00 AM	8/28/2014 9:20 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/6/2013 3:47:17 PM	9/6/2013 3:47 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/30/2012 7:41 AM
Details	Last Recertification Date	Insert				3/26/2010 11:25 AM
Details	Grant Number	Insert				3/26/2010 11:25 AM
Details	340B ID	Insert			DSH250077A	3/26/2010 11:25 AM
Details	Is Authorizing Official EHB Data	Insert				3/26/2010 11:25 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/26/2010 11:25 AM
Details	Medicare Provider Number	Insert			250077	3/26/2010 11:25 AM
Details	Entity Name	Insert			WAYNE GENERAL HOSPITAL	3/26/2010 11:25 AM
Details	Program Code	Insert			DSH	3/26/2010 11:25 AM
Details	Entity Subname	Insert			WAYNE GENERAL HOSPICE	3/26/2010 11:25 AM
Dates	Participating Approval Date	Insert			3/17/2010 12:00:00 AM	3/26/2010 11:25 AM
Details	State	Insert			Active	3/26/2010 11:25 AM
Dates	Registration Date	Insert			3/17/2010 12:00:00 AM	3/26/2010 11:25 AM
Dates	Signed By Date	Insert			1/7/2010 12:00:00 AM	3/26/2010 11:25 AM
Dates	Start Date	Insert			4/1/2010 12:00:00 AM	3/26/2010 11:25 AM
Terminations	Termination Comments	Insert				3/26/2010 11:25 AM
Terminations	Termination Date	Insert				3/26/2010 11:25 AM
Terminations	Termination Effective Date	Insert				3/26/2010 11:25 AM
Terminations	Termination Reason	Insert				3/26/2010 11:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	3/17/2010 12:12 PM
Medicaid Billing	Medicaid: Number	Insert			00770036	3/17/2010 12:12 PM
Medicaid Billing	Medicaid: State	Insert			MS	3/17/2010 12:12 PM