Covered Entity Details

DSH250099C GREENWOOD LEFLORE HOSPITAL (Terminated) - information as of 5/25/2025 1:15:56 AM

Main Details

Name

GREENWOOD LEFLORE HOSPITAL

Subdivision Name

LEXINGTON PRIMARY CARE CLINIC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH250099C

Medicare Provider Number

250099

Outpatient Facility Provider Number

253490

Additional Details

Current Program Status

Terminated

Registration Date

7/6/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/13/2013

Last Recertification Date

8/28/2019

Termination Date
Termination Reason

10/1/2020
Site closure

Contacts

Authorizing Official

Greenwood Lefore Hospital
Dawne Holmes, CFO
(662) 459-7119

Primary Contact

Greenwood Leflore Hospital
Natalie L Mainelli, Director of Pharmacy
(662) 459-2633

Addresses

Street Address

110 TCHULA ST
Lexington, MS 39095

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
MS	09015105

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
DSH250099A	Child	DSH	GREENWOOD LEFLORE HOSPITAL	WALK IN CLINIC	706 HWY 82	Greenwood	MS	Terminated
DSH250099B	Child	DSH	GREENWOOD LEFLORE HOSPITAL	AFTER HOURS CLINIC	1601 STRONG AVE	Greenwood	MS	Active
DSH250099C	Child	DSH	GREENWOOD LEFLORE HOSPITAL	LEXINGTON PRIMARY CARE CLINIC	110 TCHULA ST	Lexington	MS	Terminated
DSH250099D	Child	DSH	GREENWOOD LEFLORE HOSPITAL	MAGNOLIA MEDICAL CLINIC	1413 STRONG AVE.	Greenwood	MS	Terminated
DSH250099E	Child	DSH	GREENWOOD LEFLORE HOSPITAL	ITTA BENA CLINIC	103 BASKET ST	Itta Bena	MS	Active
DSH250099F	Child	DSH	GREENWOOD LEFLORE HOSPITAL	SUMNER CLINIC	100 NORTH COURT SQUARE	SUMNER	MS	Terminated
DSH250099G	Child	DSH	GREENWOOD LEFLORE HOSPITAL	greenwoodOB/GYN clinic - OB/GYN	203 9th st	Greenwood	MS	Terminated
DSH250099H	Child	DSH	GREENWOOD LEFLORE HOSPITAL	Greenwood Childrens Clinic - Peds	1405 Strong Ave	Greenwood	MS	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		7/1/2020 12:00:00 AM	8/20/2020 12:15 PM
Details	State	Update	Recertification	Active	To Be Terminated	8/20/2020 12:15 PM
Terminations	Termination Date	Update	Recertification		10/1/2020 12:00:00 AM	8/20/2020 12:15 PM
Terminations	Termination Effective Date	Update	Recertification		7/31/2020 12:00:00 AM	8/20/2020 12:15 PM
Terminations	Termination Reason	Update	Recertification		Site closure	8/20/2020 12:15 PM
Contacts	Primary Contact	Update	Recertification	Kidd, Dean DIRECTOR OF PHARMACY Greenwood Leflore Hospital 6624592633	Mainelli, Natalie L Director of Pharmacy Greenwood Leflore Hospital 6624592633	8/28/2019 8:57 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 6:12:17 PM	8/28/2019 8:57:09 AM	8/28/2019 8:57 AM
Details	Last Recertification Date	Update	Recertification	11/10/2017 3:25:44 PM	8/15/2018 6:12:17 PM	8/15/2018 6:12 PM
Contacts	Authorizing Official	Update	Change Request	Jackson Jr., James H. CEO Greenwood Leflore Hospital 6624592506	Holmes, Dawne CFO Greenwood Lefore Hospital 6624597119	3/28/2018 8:11 AM
Details	Last Recertification Date	Update	Recertification	8/11/2016 12:00:00 AM	11/10/2017 3:25:44 PM	11/10/2017 3:25 PM
Contacts	Primary Contact	Update		Kidd, Dean DIRECTOR OF PHARMACY 6624592633	Kidd, Dean DIRECTOR OF PHARMACY Greenwood Leflore Hospital 6624592633	10/18/2017 4:26 PM
Contacts	Authorizing Official	Update		Jackson Jr., James H. CEO 6624592506	Jackson Jr., James H. CEO Greenwood Leflore Hospital 6624592506	10/3/2017 4:45 PM
Contacts	Signed By	Update		Jackson Jr., James H. CEO 6624592506	Jackson Jr., James H. CEO Greenwood Leflore Hospital 6624592506	10/3/2017 4:45 PM
Addresses	Main Address	Insert			110 TCHULA ST Lexington, MS 39095	8/11/2016 11:58 AM
Contacts	Authorizing Official	Insert			Jackson Jr., James H. CEO 6624592506	8/11/2016 11:58 AM
Contacts	Signed By	Insert			Jackson Jr., James H. CEO 6624592506	8/11/2016 11:58 AM
Contacts	Primary Contact	Insert			Kidd, Dean DIRECTOR OF PHARMACY 6624592633	8/11/2016 11:58 AM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/11/2016 12:00:00 AM	8/11/2016 11:58 AM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 10:42 AM
Medicaid Billing	Medicaid: Number	Update		253490	09015105	8/26/2014 1:30 PM
Details	Last Recertification Date	Update			8/26/2014 12:00:00 AM	8/26/2014 1:30 PM
Dates	Participating Approval Date	Update			9/13/2013 12:00:00 AM	9/13/2013 9:15 AM
Details	State	Update		Pending	Active	9/13/2013 9:15 AM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/13/2013 9:15 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH250099C	7/30/2013 7:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2013 3:51 PM
Medicaid Billing	Medicaid: Number	Insert			253490	7/6/2013 3:51 PM
Medicaid Billing	Medicaid: State	Insert			MS	7/6/2013 3:51 PM
Details	Last Recertification Date	Insert				7/6/2013 3:51 PM
Details	Grant Number	Insert				7/6/2013 3:51 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/6/2013 3:51 PM
Details	Is Authorizing Official EHB Data	Insert				7/6/2013 3:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/6/2013 3:51 PM
Details	Medicare Provider Number	Insert			250099	7/6/2013 3:51 PM
Details	Entity Name	Insert			GREENWOOD LEFLORE HOSPITAL	7/6/2013 3:51 PM
Details	Program Code	Insert			DSH	7/6/2013 3:51 PM
Details	Entity Subname	Insert			LEXINGTON PRIMARY CARE CLINIC	7/6/2013 3:51 PM
Dates	Participating Approval Date	Insert				7/6/2013 3:51 PM
Details	State	Insert			Pending	7/6/2013 3:51 PM
Dates	Registration Date	Insert			7/6/2013 12:00:00 AM	7/6/2013 3:51 PM
Dates	Signed By Date	Insert			7/6/2013 12:00:00 AM	7/6/2013 3:51 PM
Dates	Start Date	Insert				7/6/2013 3:51 PM
Terminations	Termination Comments	Insert				7/6/2013 3:51 PM
Terminations	Termination Date	Insert				7/6/2013 3:51 PM
Terminations	Termination Effective Date	Insert				7/6/2013 3:51 PM
Terminations	Termination Reason	Insert				7/6/2013 3:51 PM