Covered Entity Details

DSH340096A LEXINGTON MEMORIAL HOSPITAL, INC. (Terminated) - information as of 6/6/2025 12:35:57 PM

Main Details

Name

LEXINGTON MEMORIAL HOSPITAL, INC.

Subdivision Name

Hematology Oncology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH340096A

Medicare Provider Number

340096

Outpatient Facility Provider Number

340096

Additional Details

Current Program Status

Terminated

Registration Date

1/14/2013

Participating Start Date

4/1/2013

Participating Approval Date

3/8/2013

Last Recertification Date

8/27/2019

Termination Date
Termination Reason

1/1/2020
DSH percentage below statutory minimum

Contacts

Authorizing Official

Lexington Memorial Hospital, Inc.
DANNY SQUIRES, CFO
(336) 248-5161

Primary Contact

North Carolina Baptist Hospital
Bibi W Wishart, Program Director, 340B
(336) 713-3426

Addresses

Street Address

107 W Medical Park Dr Ste 102
Lexington, NC 27292

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
NC	3400096
		1417958331

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	BAPTIST HOSPITAL SPECIALTY RX	NORTH TOWER GROUND FLOOR	MEDICAL CENTER BLVD	WINSTON SALEM	NC	27157	04/18/2018	07/01/2018	04/16/2018	06/18/2018
Contract Detail	BAPTIST HOSPITAL SPECIALTY RX	NORTH TOWER GROUND FLOOR	MEDICAL CENTER BLVD	WINSTON SALEM	NC	27157	04/18/2018	07/01/2018	04/16/2018	06/18/2018
Contract Detail	COMPREHENSIVE CANCER CENTER PHARMACY	NORTH CAROLINA BAPTIST HOSPITAL	MEDICAL CENTER BLVD	WINSTON SALEM	NC	27157	04/18/2018	07/01/2018	04/16/2018	06/18/2018
Contract Detail	COMPREHENSIVE CANCER CENTER PHARMACY	NORTH CAROLINA BAPTIST HOSPITAL	MEDICAL CENTER BLVD	WINSTON SALEM	NC	27157	04/18/2018	07/01/2018	04/16/2018	06/18/2018
Contract Detail	NC BAPTIST HOSPITAL, INC	MEDICAL CENTER BLVD	ATTN NC BAPTIST HOSP PHAR	WINSTON SALEM	NC	27157	04/18/2018	07/01/2018	04/16/2018	06/18/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH340096A	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Hematology Oncology	107 W Medical Park Dr Ste 102	Lexington	NC	Terminated
DSH340096B	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Women's Center of North Davidson	799 Hickory Tree Road	Winston-Salem	NC	Terminated
DSH340096C	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Women's Services Lexington	7 Medical Park Drive	Lexington	NC	Terminated
DSH340096D	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Neurosciences- Lexington	10 Medical Park Drive	Lexington	NC	Terminated
DSH340096E	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	ENT/ Head and Neck Surgery	106 W Medical Park Drive Suite C	Lexington	NC	Terminated
DSH340096F	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Cardiology	14 Medical Park Drive	Lexington	NC	Terminated
DSH340096G	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Gynecology- Lexington	106 W Medical Park Drive Suite B	Lexington	NC	Terminated
DSH340096H	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Pediatrics & Adolescents- Lexington	13 Medical Park Drive	Lexington	NC	Terminated
DSH340096J	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Digestive Services- Lexington	11 Medical Park Drive	Lexington	NC	Terminated
DSH340096K	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Internal Medicine- Lexington	105 Hospital Drive	Lexington	NC	Terminated
DSH340096L	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Family Medicine- Lexington	101 West Medical Park Drive	Lexington	NC	Terminated
DSH340096M	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Family Medicine - North Davidson	799 Hickory Tree Road	Winston-Salem	NC	Terminated
DSH340096N	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Pain Clinic	10 Medical Park Drive	Lexington	NC	Terminated
DSH340096P	Child	DSH	LEXINGTON MEMORIAL HOSPITAL, INC.	Wound Care Center	10 Medical Park Drive	Lexington	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	AO Change Request	Wishart, Bibi Program Director, 340B North Carolina Baptist Hospital 3367133426	Wishart, Bibi W Program Director, 340B North Carolina Baptist Hospital 3367133426	9/30/2024 9:45 AM
Contacts	Primary Contact	Update	Profile Change Request	Wishart, Bibi System Manager, 340B North Carolina Baptist Hospital 3367133426	Wishart, Bibi Program Director, 340B North Carolina Baptist Hospital 3367133426	1/10/2023 4:36 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2020 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		11/26/2019 12:00:00 AM	12/9/2019 4:13 PM
Details	State	Update	Termination Request	Active	To Be Terminated	12/9/2019 4:13 PM
Terminations	Termination Date	Update	Termination Request		1/1/2020 12:00:00 AM	12/9/2019 4:13 PM
Terminations	Termination Effective Date	Update	Termination Request		11/29/2019 12:00:00 AM	12/9/2019 4:13 PM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	12/9/2019 4:13 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 8:38:46 AM	8/27/2019 10:05:55 AM	8/27/2019 10:05 AM
Contacts	Primary Contact	Update	Profile Change Request	Wishart, Bibi Interim Assistant Director North Carolina Baptist Hospital 3367133426	Wishart, Bibi System Manager, 340B North Carolina Baptist Hospital 3367133426	6/3/2019 12:07 PM
Contacts	Primary Contact	Update	Change Request	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL 3367139418	Wishart, Bibi Interim Assistant Director North Carolina Baptist Hospital 3367133426	9/21/2018 9:39 AM
Details	Last Recertification Date	Update	Recertification	12/4/2017 5:11:03 PM	8/16/2018 8:38:46 AM	8/16/2018 8:38 AM
Contacts	Primary Contact	Update	Profile Change Request	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center 3367139418	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL 3367139418	8/6/2018 1:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/8/2018 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3400096	5/8/2018 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	5/8/2018 8:06 AM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	12/4/2017 5:11:03 PM	12/4/2017 5:11 PM
Contacts	Primary Contact	Update	Profile Change Request	Konopko, Martin System Manager 340b Wake Forest Baptist Health 3367139418	Konopko, Martin System Manager 340b NORTH CAROLINA BAPTIST HOSPITAL dba Wake Forest Baptist Medical Center 3367139418	11/13/2017 12:04 PM
Contacts	Primary Contact	Insert	Change Request		Konopko, Martin System Manager 340b Wake Forest Baptist Health 3367139418	10/4/2017 1:19 PM
Contacts	Authorizing Official	Update	Change Request	SQUIRES, DANNY CFO 3362485161	SQUIRES, DANNY CFO Lexington Memorial Hospital, Inc. 3362485161	9/29/2017 1:39 PM
Contacts	Signed By	Update	Change Request	SQUIRES, DANNY CFO 3362485161	SQUIRES, DANNY CFO Lexington Memorial Hospital, Inc. 3362485161	9/29/2017 1:39 PM
Contacts	Authorizing Official	Insert			SQUIRES, DANNY CFO 3362485161	6/20/2017 11:01 AM
Contacts	Signed By	Insert			SQUIRES, DANNY CFO 3362485161	6/20/2017 11:01 AM
Addresses	Main Address	Insert			107 W Medical Park Dr Ste 102 Lexington, NC 27292	6/20/2017 10:54 AM
Medicaid Billing	NPI: Number	Insert			1417958331	9/6/2016 11:10 AM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 11:10 AM
Details	Last Recertification Date	Update		8/29/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 11:31 AM
Details	Last Recertification Date	Update		8/29/2013 2:12:40 PM	8/29/2014 12:00:00 AM	8/29/2014 10:24 AM
Details	Last Recertification Date	Update			8/29/2013 2:12:40 PM	8/29/2013 2:12 PM
Details	340B ID	Update		ISBLDSH340096A	DSH340096A	3/8/2013 9:58 AM
Dates	Participating Approval Date	Update			3/8/2013 12:00:00 AM	3/8/2013 9:58 AM
Details	State	Update		Pending	Active	3/8/2013 9:58 AM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	3/8/2013 9:58 AM
Details	340B ID	Update		BL011413C	ISBLDSH340096A	2/27/2013 2:32 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	BL011413C	1/15/2013 5:55 AM
Details	Last Recertification Date	Insert				1/14/2013 10:45 AM
Details	Grant Number	Insert				1/14/2013 10:45 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/14/2013 10:45 AM
Details	Is Authorizing Official EHB Data	Insert				1/14/2013 10:45 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/14/2013 10:45 AM
Details	Medicare Provider Number	Insert			340096	1/14/2013 10:45 AM
Details	Entity Name	Insert			LEXINGTON MEMORIAL HOSPITAL, INC.	1/14/2013 10:45 AM
Details	Program Code	Insert			DSH	1/14/2013 10:45 AM
Details	Entity Subname	Insert			Hematology Oncology	1/14/2013 10:45 AM
Dates	Participating Approval Date	Insert				1/14/2013 10:45 AM
Details	State	Insert			Pending	1/14/2013 10:45 AM
Dates	Registration Date	Insert			1/14/2013 12:00:00 AM	1/14/2013 10:45 AM
Dates	Signed By Date	Insert			1/14/2013 12:00:00 AM	1/14/2013 10:45 AM
Dates	Start Date	Insert				1/14/2013 10:45 AM
Terminations	Termination Comments	Insert				1/14/2013 10:45 AM
Terminations	Termination Date	Insert				1/14/2013 10:45 AM
Terminations	Termination Effective Date	Insert				1/14/2013 10:45 AM
Terminations	Termination Reason	Insert				1/14/2013 10:45 AM