Covered Entity Details

SCH250095-01 South Sunflower County Hospital (Active) - information as of 4/28/2025 12:44:23 AM

Main Details

Name

South Sunflower County Hospital

Subdivision Name

South Sunflower County Hospital dba Indianola Family Medical Group

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH250095-01

Medicare Provider Number

250095

Outpatient Facility Provider Number

258525

Additional Details

Current Program Status

Active

Registration Date

7/1/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/11/2013

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

South Sunflower County Hospital
Courtney Phillips, Administrator/CFO
(662) 635-7200

Primary Contact

South Sunflower County Hospital
Britney Jacobs, Risk Manager
(662) 635-7205

Addresses

Street Address

122 East Baker Street
Indianola, MS 38751-2451

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH250095-01	Child	SCH	South Sunflower County Hospital	South Sunflower County Hospital dba Indianola Family Medical Group	122 East Baker Street	Indianola	MS	Active
SCH250095-02	Child	SCH	South Sunflower County Hospital	Delta Primary Clinic - Clinic	110 East Baker	Indianola	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 10:55:17 AM	8/16/2024 10:35:45 AM	8/16/2024 10:35 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 10:15:36 AM	8/16/2023 10:55:17 AM	8/16/2023 10:55 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 10:56:52 AM	8/26/2022 10:15:36 AM	8/26/2022 10:15 AM
Details	Last Recertification Date	Update	Recertification	8/17/2020 11:12:53 AM	8/16/2021 10:56:52 AM	8/16/2021 10:56 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 2:50:42 PM	8/17/2020 11:12:53 AM	8/17/2020 11:12 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 11:26:23 AM	8/20/2019 2:50:42 PM	8/20/2019 2:50 PM
Contacts	Primary Contact	Update	Recertification	Sparks, Holly Howard Administrator/CCO South Sunflower County Hospital 6626357219	Jacobs, Britney Risk Manager South Sunflower County Hospital 6626357205	8/22/2018 11:26 AM
Details	Last Recertification Date	Update	Recertification	11/7/2017 11:12:43 AM	8/22/2018 11:26:23 AM	8/22/2018 11:26 AM
Contacts	Primary Contact	Update	Recertification	Sandling, Candice Administrative Assistant 6628872208-2119	Sparks, Holly Howard Administrator/CCO South Sunflower County Hospital 6626357219	11/7/2017 11:12 AM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/7/2017 11:12:43 AM	11/7/2017 11:12 AM
Contacts	Authorizing Official	Update		Phillips, Courtney Administrator/CFO 6626357200	Phillips, Courtney Administrator/CFO South Sunflower County Hospital 6626357200	10/13/2017 4:57 PM
Contacts	Authorizing Official	Insert			Phillips, Courtney Administrator/CFO 6626357200	1/11/2017 9:06 AM
Addresses	Main Address	Insert			122 East Baker Street Indianola, MS 38751-2451	8/10/2016 10:46 AM
Contacts	Signed By	Insert			Blessitt, H. J. Administrator 6628875235-1500	8/10/2016 10:46 AM
Contacts	Primary Contact	Insert			Sandling, Candice Administrative Assistant 6628872208-2119	8/10/2016 10:46 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 10:46 AM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 11:27 AM
Details	Last Recertification Date	Update			8/21/2014 12:00:00 AM	8/21/2014 1:54 PM
Details	340B ID	Update		250095-01	SCH250095-01	9/11/2013 4:09 PM
Dates	Participating Approval Date	Update			9/11/2013 12:00:00 AM	9/11/2013 4:09 PM
Details	State	Update		Pending	Active	9/11/2013 4:09 PM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/11/2013 4:09 PM
Details	340B ID	Update		ISJM250095-00	250095-01	9/3/2013 4:38 PM
Details	340B ID	Update		JM250095	ISJM250095-00	8/19/2013 10:20 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	JM250095	8/16/2013 11:34 AM
Details	Last Recertification Date	Insert				7/1/2013 4:53 PM
Details	Grant Number	Insert				7/1/2013 4:53 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/1/2013 4:53 PM
Details	Is Authorizing Official EHB Data	Insert				7/1/2013 4:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/1/2013 4:53 PM
Details	Medicare Provider Number	Insert			250095	7/1/2013 4:53 PM
Details	Entity Name	Insert			South Sunflower County Hospital	7/1/2013 4:53 PM
Details	Program Code	Insert			SCH	7/1/2013 4:53 PM
Details	Entity Subname	Insert			South Sunflower County Hospital dba Indianola Family Medical Group	7/1/2013 4:53 PM
Dates	Participating Approval Date	Insert				7/1/2013 4:53 PM
Details	State	Insert			Pending	7/1/2013 4:53 PM
Dates	Registration Date	Insert			7/1/2013 12:00:00 AM	7/1/2013 4:53 PM
Dates	Signed By Date	Insert			7/1/2013 12:00:00 AM	7/1/2013 4:53 PM
Dates	Start Date	Insert				7/1/2013 4:53 PM
Terminations	Termination Comments	Insert				7/1/2013 4:53 PM
Terminations	Termination Date	Insert				7/1/2013 4:53 PM
Terminations	Termination Effective Date	Insert				7/1/2013 4:53 PM
Terminations	Termination Reason	Insert				7/1/2013 4:53 PM