Covered Entity Details

CAH251309-03 FIELD MEMORIAL COMMUNITY HOSPITAL (Active) - information as of 6/2/2025 8:27:14 AM

Main Details

Name

FIELD MEMORIAL COMMUNITY HOSPITAL

Subdivision Name

GLOSTER CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH251309-03

Medicare Provider Number

251309

Outpatient Facility Provider Number

258503

Additional Details

Current Program Status

Active

Registration Date

10/6/2010

Participating Start Date

1/1/2011

Participating Approval Date

10/7/2010

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Field Memorial Community Hospital
Bernard Richard Williams, III, CEO/Administrator
(601) 890-0545

Primary Contact

Field Memorial Community Hospital
Vicki Anders, CFO
(601) 890-0546

Addresses

Street Address

434 N CAPTAIN GLOSTER DR
GLOSTER, MS 39638

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?
No

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
Contract Detail	JELKS FAMILY PHARMACY	1404 ACADEMY STREET		CENTREVILLE	MS	39631	01/03/2020	04/01/2020			04/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH251309-01	Child	CAH	FIELD MEMORIAL COMMUNITY HOSPITAL	CATCHINGS CLINIC	451 BANK STREET	WOODVILLE	MS	Active
CAH251309-02	Child	CAH	FIELD MEMORIAL COMMUNITY HOSPITAL	CENTREVILLE CLINIC	178 HWY 24 E SUITE A	CENTREVILLE	MS	Active
CAH251309-03	Child	CAH	FIELD MEMORIAL COMMUNITY HOSPITAL	GLOSTER CLINIC	434 N CAPTAIN GLOSTER DR	GLOSTER	MS	Active
CAH251309-04	Child	CAH	FIELD MEMORIAL COMMUNITY HOSPITAL	FMCH / LIBERTY CLINIC	1410 MAIN E ST	LIBERTY	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 1:19:42 PM	8/19/2024 11:04:17 AM	8/19/2024 11:04 AM
Contacts	Primary Contact	Update	Recertification	Mix, Sherry F CFO Field Memorial Community Hospital 6018900546	Anders, Vicki CFO Field Memorial Community Hospital 6018900546	8/17/2023 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/25/2022 10:36:40 AM	8/17/2023 1:19:42 PM	8/17/2023 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/22/2021 9:18:17 PM	8/25/2022 10:36:40 AM	8/25/2022 10:36 AM
Contacts	Authorizing Official	Update	Change Request	NETTERVILLE, CHAD CEO Field Memorial Community Hospital 6018900545	Williams, III, Bernard Richard CEO/Administrator Field Memorial Community Hospital 6018900545	3/3/2022 8:25 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 3:32:54 PM	8/22/2021 9:18:17 PM	8/22/2021 9:18 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	09016303 (MS)		10/14/2020 12:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144274622 (MS)		10/14/2020 12:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144274622	9/2/2020 3:32 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/2/2020 3:32 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1144274622 ( )		9/2/2020 3:32 PM
Contacts	Primary Contact	Update	Recertification	MAGEE, MICHAEL CFO Field Memorial Community Hospital 6018900546	Mix, Sherry F CFO Field Memorial Community Hospital 6018900546	9/2/2020 3:32 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 9:27:21 AM	9/2/2020 3:32:54 PM	9/2/2020 3:32 PM
Contacts	Authorizing Official	Update	Change Request	Mix, Sherry F CFO Field Memorial Community Hospital 6018900546	NETTERVILLE, CHAD CEO Field Memorial Community Hospital 6018900545	1/6/2020 10:54 AM
Contacts	Authorizing Official	Update	AO Change Request	NETTERVILLE, CHAD CEO Field Memorial Community Hospital 6018900545	Mix, Sherry F CFO Field Memorial Community Hospital 6018900546	1/2/2020 6:48 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 10:57:35 AM	9/5/2019 9:27:21 AM	9/5/2019 9:27 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 10:21:22 AM	8/20/2018 10:57:35 AM	8/20/2018 10:57 AM
Contacts	Primary Contact	Update	Change Request	JELKS, JAMIE DIRECTOR OF PHARMACY 6018900592	MAGEE, MICHAEL CFO Field Memorial Community Hospital 6018900546	11/13/2017 10:37 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/13/2017 10:21:22 AM	11/13/2017 10:21 AM
Contacts	Authorizing Official	Update		NETTERVILLE, CHAD CEO 6018900545	NETTERVILLE, CHAD CEO Field Memorial Community Hospital 6018900545	10/31/2017 11:30 AM
Contacts	Authorizing Official	Insert			NETTERVILLE, CHAD CEO 6018900545	5/1/2017 11:49 AM
Addresses	Main Address	Insert			434 N CAPTAIN GLOSTER DR GLOSTER, MS 39638	10/31/2016 11:32 AM
Contacts	Primary Contact	Update		WATTS, JOEY RPH 6016455221	JELKS, JAMIE DIRECTOR OF PHARMACY 6018900592	10/31/2016 11:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/18/2016 1:53 PM
Medicaid Billing	Medicaid: Number	Insert			09016303	8/18/2016 1:53 PM
Medicaid Billing	Medicaid: State	Insert			MS	8/18/2016 1:53 PM
Medicaid Billing	NPI: Number	Insert			1144274622	8/18/2016 1:53 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 1:53 PM
Contacts	Primary Contact	Insert			WATTS, JOEY RPH 6016455221	8/10/2015 10:40 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 10:40 AM
Details	Last Recertification Date	Update		9/13/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 7:32 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/13/2013 12:00:00 AM	9/13/2013 9:04 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	6/1/2012 7:44 AM
Details	Last Recertification Date	Insert				10/7/2010 7:45 AM
Details	Grant Number	Insert				10/7/2010 7:45 AM
Details	340B ID	Insert			CAH251309-03	10/7/2010 7:45 AM
Details	Is Authorizing Official EHB Data	Insert				10/7/2010 7:45 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/7/2010 7:45 AM
Details	Medicare Provider Number	Insert			251309	10/7/2010 7:45 AM
Details	Entity Name	Insert			FIELD MEMORIAL COMMUNITY HOSPITAL	10/7/2010 7:45 AM
Details	Program Code	Insert			CAH	10/7/2010 7:45 AM
Details	Entity Subname	Insert			GLOSTER CLINIC	10/7/2010 7:45 AM
Dates	Participating Approval Date	Insert			10/7/2010 12:00:00 AM	10/7/2010 7:45 AM
Details	State	Insert			Active	10/7/2010 7:45 AM
Dates	Registration Date	Insert			10/6/2010 12:00:00 AM	10/7/2010 7:45 AM
Dates	Signed By Date	Insert			8/26/2010 12:00:00 AM	10/7/2010 7:45 AM
Dates	Start Date	Insert			1/1/2011 12:00:00 AM	10/7/2010 7:45 AM
Terminations	Termination Comments	Insert				10/7/2010 7:45 AM
Terminations	Termination Date	Insert				10/7/2010 7:45 AM
Terminations	Termination Effective Date	Insert				10/7/2010 7:45 AM
Terminations	Termination Reason	Insert				10/7/2010 7:45 AM