Covered Entity Details

DSH260070H PEMISCOT COUNTY MEMORIAL HOSPITAL (Active) - information as of 4/29/2025 1:40:50 AM

Main Details

Name

PEMISCOT COUNTY MEMORIAL HOSPITAL

Subdivision Name

Bootheel Primary Care - Caruthersville

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260070H

Medicare Provider Number

260070

Outpatient Facility Provider Number

268626

Additional Details

Current Program Status

Active

Registration Date

12/17/2010

Participating Start Date

1/1/2015

Participating Approval Date

3/9/2011

Last Recertification Date

8/14/2024

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

1502 Ward Avenue
Caruthersville, MO 63830

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
12/24/14 CE reinstated effective 1/1/15, was participating from 4/1/2011 to 9/30/13, not participating from 10/1/2013 to 12/30/14 due to failure to recertify	12/24/2014

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	596074401	1841463551

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
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	8/14/2023 4:16:14 PM	8/14/2024 5:03:42 PM	8/14/2024 5:03 PM
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	8/25/2022 9:39:53 AM	8/14/2023 4:16:14 PM	8/14/2023 4:16 PM
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	Group Change Request	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	Carpenter, Tammy 340B CPhT Pemiscot County Memorial Hospital 5733593454	1/4/2023 12:09 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 9:46:31 AM	8/25/2022 9:39:53 AM	8/25/2022 9:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2021 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		596074401	9/13/2021 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	9/13/2021 1:31 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841463551	9/13/2021 1:31 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	9/13/2021 1:31 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 9:21:57 AM	8/30/2021 9:46:31 AM	8/30/2021 9:46 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	596074401 (MO)		6/14/2021 4:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841463551 (MO)		6/14/2021 4:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1841463551	8/18/2020 9:21 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/18/2020 9:21 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1841463551 ( )		8/18/2020 9:21 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 9:54:42 PM	8/18/2020 9:21:57 AM	8/18/2020 9:21 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 9:10:29 AM	8/29/2019 9:54:42 PM	8/29/2019 9:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2019 8:56 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		596074401	3/12/2019 8:56 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	3/12/2019 8:56 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 4:51:57 PM	8/16/2018 9:10:29 AM	8/16/2018 9:10 AM
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
Contacts	Primary Contact	Update	Recertification	MEDLIN, KELLY OFFICE MANAGER 5733334244	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	11/13/2017 4:51 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/13/2017 4:51:57 PM	11/13/2017 4:51 PM
Contacts	Authorizing Official	Insert	Change Request		Marshall, Jim CEO Pemiscot Memorial Health Systems 5733593612	9/28/2017 10:51 AM
Addresses	Main Address	Insert			1502 WARD AVENUE CARUTHERSVILLE, MO 63830	8/31/2016 10:23 AM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 10:23 AM
Details	Last Recertification Date	Update			8/24/2015 12:00:00 AM	8/24/2015 10:41 AM
Details	Last Recertification Date	Update		9/14/2013 12:00:00 AM		12/24/2014 3:14 PM
Dates	Last Date That 340B Drugs Purchased	Update		10/1/2013 12:00:00 AM		12/24/2014 3:14 PM
Details	Entity Name	Update		PEMISCOT MEMORIAL HOSPITAL	PEMISCOT COUNTY MEMORIAL HOSPITAL	12/24/2014 3:14 PM
Details	Entity Subname	Update		BOOTHEEL PRIMARY CARE CLINIC - CARUTHERSVILLE	Bootheel Primary Care - Caruthersville	12/24/2014 3:14 PM
Details	State	Update		Terminated	Active	12/24/2014 3:14 PM
Dates	Start Date	Update		4/1/2011 12:00:00 AM	1/1/2015 12:00:00 AM	12/24/2014 3:14 PM
Terminations	Termination Date	Update		10/1/2013 12:00:00 AM		12/24/2014 3:14 PM
Terminations	Termination Effective Date	Update		10/1/2013 12:00:00 AM		12/24/2014 3:14 PM
Terminations	Termination Reason	Update		Failure to recertify		12/24/2014 3:14 PM
Details	Comments Public	Insert			12/24/14 CE reinstated effective 1/1/15, was participating from 4/1/2011 to 9/30/13, not participating from 10/1/2013 to 12/30/14 due to failure to recertify	12/24/2014 3:14 PM
Contacts	Primary Contact	Insert			MEDLIN, KELLY OFFICE MANAGER 5733334244	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/14/2013 12:00:00 AM	9/14/2013 7:35 AM
Dates	Last Date That 340B Drugs Purchased	Update			10/1/2013 12:00:00 AM	9/14/2013 7:35 AM
Details	State	Update		Active	Terminated	9/14/2013 7:35 AM
Terminations	Termination Date	Update			10/1/2013 12:00:00 AM	9/14/2013 7:35 AM
Terminations	Termination Effective Date	Update			10/1/2013 12:00:00 AM	9/14/2013 7:35 AM
Terminations	Termination Reason	Update			Failure to recertify	9/14/2013 7:35 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/30/2012 7:32 AM
Details	Last Recertification Date	Insert				3/9/2011 4:11 PM
Details	Grant Number	Insert				3/9/2011 4:11 PM
Details	340B ID	Insert			DSH260070H	3/9/2011 4:11 PM
Details	Is Authorizing Official EHB Data	Insert				3/9/2011 4:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert				3/9/2011 4:11 PM
Details	Medicare Provider Number	Insert			260070	3/9/2011 4:11 PM
Details	Entity Name	Insert			PEMISCOT MEMORIAL HOSPITAL	3/9/2011 4:11 PM
Details	Program Code	Insert			DSH	3/9/2011 4:11 PM
Details	Entity Subname	Insert			BOOTHEEL PRIMARY CARE CLINIC - CARUTHERSVILLE	3/9/2011 4:11 PM
Dates	Participating Approval Date	Insert			3/9/2011 12:00:00 AM	3/9/2011 4:11 PM
Details	State	Insert			Active	3/9/2011 4:11 PM
Dates	Registration Date	Insert			12/17/2010 12:00:00 AM	3/9/2011 4:11 PM
Dates	Signed By Date	Insert			3/4/2011 12:00:00 AM	3/9/2011 4:11 PM
Dates	Start Date	Insert			4/1/2011 12:00:00 AM	3/9/2011 4:11 PM
Terminations	Termination Comments	Insert				3/9/2011 4:11 PM
Terminations	Termination Date	Insert				3/9/2011 4:11 PM
Terminations	Termination Effective Date	Insert				3/9/2011 4:11 PM
Terminations	Termination Reason	Insert				3/9/2011 4:11 PM
Medicaid Billing	NPI: Number	Insert			1841463551	12/17/2010 2:02 PM