Covered Entity Details

CAH251322-04 LAIRD HOSPITAL, INC. (Active) - information as of 4/29/2025 11:55:12 PM

Main Details

Name

LAIRD HOSPITAL, INC.

Subdivision Name

RHC Collinsville LRDC CR09 - RUSH RMCC FAMILY MEDICINE

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH251322-04

Medicare Provider Number

251322

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2014

Participating Start Date

7/1/2014

Participating Approval Date

4/15/2014

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Ochsner Rush Health
David Butler, Chief Financial Officer
(601) 703-3082

Primary Contact

Laird Hospital
Kristin McDonald, Director of Pharmacy
(601) 774-1558

Addresses

Street Address

9097 Collinsville Road
Collinsville, MS 39325

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	007379233	1073959375

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
CAH251322-01	Child	CAH	LAIRD HOSPITAL, INC.	RHC Decatur Med Clin LRDC HW27 - RUSH DFMC FAMILY MEDICINE	14884 Highway 15	Decatur	MS	Active
CAH251322-02	Child	CAH	LAIRD HOSPITAL, INC.	RHC Union Med Clinic LRDC HW28 - RUSH FMUC FAMILY MEDICINE	24345 Highway 15	Union	MS	Active
CAH251322-03	Child	CAH	LAIRD HOSPITAL, INC.	Rush Central Clinic LRDC TA01 - RUSH RCCC FAMILY MEDICINE	1221 24th Avenue	Meridian	MS	Terminated
CAH251322-04	Child	CAH	LAIRD HOSPITAL, INC.	RHC Collinsville LRDC CR09 - RUSH RMCC FAMILY MEDICINE	9097 Collinsville Road	Collinsville	MS	Active
CAH251322-05	Child	CAH	LAIRD HOSPITAL, INC.	RHC Philadelph LRDC CD02 - RUSH PHLC FAMILY MEDICINE	1106 Central Drive	Philadelphia	MS	Active
CAH251322-06	Child	CAH	LAIRD HOSPITAL, INC.	Fam Med Clinic LRDC HW29 - RUSH FMCC FAMILY MEDICINE	1500 HIGHWAY 19 N	MERIDIAN	MS	Active
CAH251322-07	Child	CAH	LAIRD HOSPITAL, INC.	Newton Fam Med Clin LRDC ND01 - RUSH NEFC OBSTERICS AND GYNECOLOGY	252 Northside Drive	Newton	MS	Active
CAH251322-08	Child	CAH	LAIRD HOSPITAL, INC.	Imaging Center LRDH HW31 - RUSH PHLH CT SCAN IMAGING CENTER	1106 Central Drive	Philadelphia	MS	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Change Request	7379233 (MS)		3/13/2025 4:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/13/2025 4:40 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		007379233	3/13/2025 4:40 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	3/13/2025 4:40 PM
Contacts	Primary Contact	Update	Change Request	McDonald, Kristin Director of Pharmacy Laird Hospital 6017741558	McDonald, Kristin Director of Pharmacy Laird Hospital 6017741558	2/23/2025 8:31 AM
Details	Last Recertification Date	Update	Recertification	9/8/2023 1:38:22 PM	9/3/2024 6:11:53 PM	9/3/2024 6:11 PM
Details	Entity Subname	Update	Recertification	Rush Medical Clinic-Collinsville	RHC Collinsville LRDC CR09 - RUSH RMCC FAMILY MEDICINE	9/3/2024 6:11 PM
Contacts	Authorizing Official	Update	AO Change Request	Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	Butler, David Chief Financial Officer Ochsner Rush Health 6017033082	5/29/2024 6:42 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 1:25:19 PM	9/8/2023 1:38:22 PM	9/8/2023 1:38 PM
Details	Last Recertification Date	Update	Recertification	8/18/2021 7:45:41 AM	9/7/2022 1:25:19 PM	9/7/2022 1:25 PM
Contacts	Authorizing Official	Update	Change Request	Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	8/2/2022 6:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/10/2022 4:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7379233	6/10/2022 4:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	6/10/2022 4:34 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073959375	6/10/2022 4:34 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	6/10/2022 4:34 PM
Contacts	Primary Contact	Update	Recertification	McDonald, Kristin Director of Pharmacy Laird Hospital 6017741558	McDonald, Kristin Director of Pharmacy Laird Hospital 6017741558	8/18/2021 7:45 AM
Details	Last Recertification Date	Update	Recertification	8/17/2020 11:10:54 AM	8/18/2021 7:45:41 AM	8/18/2021 7:45 AM
Contacts	Authorizing Official	Update	Change Request	Mize, Suzanne 340B Administrator Rush Health Systems 2054599180	Mize, Suzanne H 340B Administrator Rush Health Systems 2054599180	4/14/2021 8:36 AM
Details	Last Recertification Date	Update	Recertification	8/27/2019 10:59:26 AM	8/17/2020 11:10:54 AM	8/17/2020 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/17/2018 12:08:21 PM	8/27/2019 10:59:26 AM	8/27/2019 10:59 AM
Details	Last Recertification Date	Update	Recertification	11/3/2017 4:22:30 PM	8/17/2018 12:08:21 PM	8/17/2018 12:08 PM
Contacts	Authorizing Official	Update	AO Change Request	BARTLETT, THOMAS HOSPITAL ADMINISTRATOR Laird Hospital 6017748214-1500	Mize, Suzanne 340B Administrator Rush Health Systems 2054599180	12/6/2017 12:45 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/3/2017 4:22:30 PM	11/3/2017 4:22 PM
Contacts	Primary Contact	Update	Change Request	McDonald, Kristin Director of Pharmacy 6017741558	McDonald, Kristin Director of Pharmacy Laird Hospital 6017741558	10/13/2017 12:09 PM
Contacts	Authorizing Official	Update		BARTLETT, THOMAS HOSPITAL ADMINISTRATOR 6017748214-1500	BARTLETT, THOMAS HOSPITAL ADMINISTRATOR Laird Hospital 6017748214-1500	10/13/2017 11:51 AM
Contacts	Signed By	Update		BARTLETT, THOMAS HOSPITAL ADMINISTRATOR 6017748214-1500	BARTLETT, THOMAS HOSPITAL ADMINISTRATOR Laird Hospital 6017748214-1500	10/13/2017 11:51 AM
Addresses	Main Address	Insert			9097 Collinsville Road Collinsville, MS 39325	8/14/2017 6:33 AM
Contacts	Primary Contact	Update		McDonald, Kristen Director of Pharmacy 6017741558	McDonald, Kristin Director of Pharmacy 6017741558	8/14/2017 6:33 AM
Contacts	Authorizing Official	Insert			BARTLETT, THOMAS HOSPITAL ADMINISTRATOR 6017748214-1500	8/14/2017 6:33 AM
Contacts	Signed By	Insert			BARTLETT, THOMAS HOSPITAL ADMINISTRATOR 6017748214-1500	8/14/2017 6:33 AM
Contacts	Primary Contact	Insert			McDonald, Kristen Director of Pharmacy 6017741558	8/10/2016 12:08 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 12:08 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 10:13 AM
Details	Last Recertification Date	Update			8/13/2014 12:00:00 AM	8/13/2014 11:35 AM
Dates	Participating Approval Date	Update			4/15/2014 12:00:00 AM	4/15/2014 8:55 PM
Details	State	Update		Pending	Active	4/15/2014 8:55 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	4/15/2014 8:55 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	CAH251322-04	4/15/2014 6:32 PM
Details	Last Recertification Date	Insert				4/10/2014 2:29 PM
Details	Grant Number	Insert				4/10/2014 2:29 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/10/2014 2:29 PM
Details	Is Authorizing Official EHB Data	Insert				4/10/2014 2:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/10/2014 2:29 PM
Details	Medicare Provider Number	Insert			251322	4/10/2014 2:29 PM
Details	Entity Name	Insert			LAIRD HOSPITAL, INC.	4/10/2014 2:29 PM
Details	Program Code	Insert			CAH	4/10/2014 2:29 PM
Details	Entity Subname	Insert			Rush Medical Clinic-Collinsville	4/10/2014 2:29 PM
Dates	Participating Approval Date	Insert				4/10/2014 2:29 PM
Details	State	Insert			Pending	4/10/2014 2:29 PM
Dates	Registration Date	Insert			4/10/2014 12:00:00 AM	4/10/2014 2:29 PM
Dates	Signed By Date	Insert			4/10/2014 12:00:00 AM	4/10/2014 2:29 PM
Dates	Start Date	Insert				4/10/2014 2:29 PM
Terminations	Termination Comments	Insert				4/10/2014 2:29 PM
Terminations	Termination Date	Insert				4/10/2014 2:29 PM
Terminations	Termination Effective Date	Insert				4/10/2014 2:29 PM
Terminations	Termination Reason	Insert				4/10/2014 2:29 PM