Covered Entity Details

SCH110002-00 Upson County Hospital, Inc. (Active) - information as of 5/20/2025 11:42:40 PM

Main Details

Name

Upson County Hospital, Inc.

Subdivision Name

DBA Upson Regional Medical Center

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH110002-00

Medicare Provider Number

110002

Additional Details

Current Program Status

Active

Registration Date

7/2/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/11/2013

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Upson Regional Medical Center
John H Williams, CFO/COO
(706) 647-8111 Ext: 1117

Primary Contact

Upson Regional Medical Center
Joyce H Glisson, Pharmacist
(706) 647-8111 Ext: 1157

Addresses

Street Address

801 West Gordon Street
Thomaston, GA 30286

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
GA	00001988A	1659376630

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	CHEROKEE PHARMACY	200 CHEROKEE RD.	LISA V CALDWELL, RPH	THOMASTON	GA	30286	04/08/2015	07/01/2015	01/01/2018	08/30/2018
Contract Detail	CITY PHARMACY OF ZEBULON, PC	460 THOMASTON ST	GASKINS KENNETH DAVID - PIC	ZEBULON	GA	30295-3387	04/02/2015	07/01/2015	01/01/2018	08/30/2018
Contract Detail	NORTHSIDE DRUGS INC	1109 HIGHWAY 19 NORTH		THOMASTON	GA	30286-3028	04/08/2015	07/01/2015	01/01/2018	08/30/2018
Contract Detail	THOMASTON PRESCRIPTION SHOP	500 W GORDON ST		THOMASTON	GA	30286	04/14/2015	07/01/2015	01/01/2018	08/30/2018
Contract Detail	WAL-MART PHARMACY 10-1112	855 N. CHURCH STREET		THOMASTON	GA	30286	01/05/2015	04/01/2015	01/01/2018	08/30/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH110002-01	Child	SCH	Upson County Hospital, Inc.	UPSON REGIONAL MED CENTER CLINIC - Rural Health Clinic	206 CHEROKEE RD	THOMASTON	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	Glisson, Joyce Director of Pharmacy Upson Regional Medical Center 7066478111-1157	Glisson, Joyce H Pharmacist Upson Regional Medical Center 7066478111-1157	8/12/2024 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/23/2023 9:17:05 AM	8/12/2024 11:10:57 AM	8/12/2024 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 12:56:36 PM	8/23/2023 9:17:05 AM	8/23/2023 9:17 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 2:39:39 PM	8/24/2022 12:56:36 PM	8/24/2022 12:56 PM
Details	Last Recertification Date	Update	Recertification	8/24/2020 8:06:49 AM	9/9/2021 2:39:39 PM	9/9/2021 2:39 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	8/24/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification	8/28/2019 11:45:15 AM	8/24/2020 8:06:49 AM	8/24/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification	8/24/2018 7:54:24 AM	8/28/2019 11:45:15 AM	8/28/2019 11:45 AM
Contacts	Authorizing Official	Update		Williams, John H CFO Upson Regional Medical Center 7066478111-1117	Williams, John H CFO/COO Upson Regional Medical Center 7066478111-1117	8/26/2019 11:26 AM
Contacts	Signed By	Update		Williams, John H CFO Upson Regional Medical Center 7066478111-1117	Williams, John H CFO/COO Upson Regional Medical Center 7066478111-1117	8/26/2019 11:26 AM
Details	Last Recertification Date	Update	Recertification	12/5/2017 7:32:28 PM	8/24/2018 7:54:24 AM	8/24/2018 7:54 AM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	12/5/2017 7:32:28 PM	12/5/2017 7:32 PM
Contacts	Primary Contact	Update		Glisson, Joyce Director of Pharmacy 7066478111-1157	Glisson, Joyce Director of Pharmacy Upson Regional Medical Center 7066478111-1157	10/10/2017 9:53 AM
Contacts	Authorizing Official	Update		Williams, John CFO 7066478111-1117	Williams, John H CFO Upson Regional Medical Center 7066478111-1117	10/9/2017 11:03 AM
Contacts	Signed By	Update		Williams, John CFO 7066478111-1117	Williams, John H CFO Upson Regional Medical Center 7066478111-1117	10/9/2017 11:03 AM
Addresses	Main Address	Insert			801 West Gordon Street Thomaston, GA 30286	8/24/2016 11:35 AM
Contacts	Primary Contact	Insert			Glisson, Joyce Director of Pharmacy 7066478111-1157	8/24/2016 11:35 AM
Contacts	Authorizing Official	Insert			Williams, John CFO 7066478111-1117	8/24/2016 11:35 AM
Contacts	Signed By	Insert			Williams, John CFO 7066478111-1117	8/24/2016 11:35 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 11:35 AM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 9:56 AM
Details	Last Recertification Date	Update			8/19/2014 12:00:00 AM	8/19/2014 1:08 PM
Dates	Participating Approval Date	Update			9/11/2013 12:00:00 AM	9/11/2013 4:06 PM
Details	State	Update		Pending	Active	9/11/2013 4:06 PM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/11/2013 4:06 PM
Details	340B ID	Update		ONLINE_REG	SCH110002-00	7/19/2013 8:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/2/2013 3:25 PM
Medicaid Billing	Medicaid: Number	Insert			00001988A	7/2/2013 3:25 PM
Medicaid Billing	Medicaid: State	Insert			GA	7/2/2013 3:25 PM
Medicaid Billing	NPI: Number	Insert			1659376630	7/2/2013 3:25 PM
Details	Last Recertification Date	Insert				7/2/2013 3:25 PM
Details	Grant Number	Insert				7/2/2013 3:25 PM
Details	340B ID	Insert			ONLINE_REG	7/2/2013 3:25 PM
Details	Is Authorizing Official EHB Data	Insert				7/2/2013 3:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/2/2013 3:25 PM
Details	Medicare Provider Number	Insert			110002	7/2/2013 3:25 PM
Details	Entity Name	Insert			Upson County Hospital, Inc.	7/2/2013 3:25 PM
Details	Program Code	Insert			SCH	7/2/2013 3:25 PM
Details	Entity Subname	Insert			DBA Upson Regional Medical Center	7/2/2013 3:25 PM
Dates	Participating Approval Date	Insert				7/2/2013 3:25 PM
Details	State	Insert			Pending	7/2/2013 3:25 PM
Dates	Registration Date	Insert			7/2/2013 12:00:00 AM	7/2/2013 3:25 PM
Dates	Signed By Date	Insert			7/2/2013 12:00:00 AM	7/2/2013 3:25 PM
Dates	Start Date	Insert				7/2/2013 3:25 PM
Terminations	Termination Comments	Insert				7/2/2013 3:25 PM
Terminations	Termination Date	Insert				7/2/2013 3:25 PM
Terminations	Termination Effective Date	Insert				7/2/2013 3:25 PM
Terminations	Termination Reason	Insert				7/2/2013 3:25 PM