Covered Entity Details

CAH451358-02 MEMORIAL HOSPITAL-SEMINOLE (Active) - information as of 5/1/2025 11:52:16 PM

Main Details

Name

MEMORIAL HOSPITAL-SEMINOLE

Subdivision Name

Rural Health Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH451358-02

Medicare Provider Number

451358

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/14/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/28/2019

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Seminole Memorial Hospital
Maegen Garner, Interim CEO
(432) 758-4814

Primary Contact

Seminole Memorial Hospital
Deborah Anne Dabbs, Compliance Officer
(432) 758-4868

Addresses

Street Address

209 NW 8th Street
Seminole, TX 79360

Billing Address

CAH PHCY SRVCS DIV 16
13651 DUBLIN COURT
Stafford, TX 77477

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date 01/01/2016) ) until terminated effective date (10/1/2018), reinstatement effective date (04/01/2019)	01/16/2019

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
TX	0941213-03,402788001,402473901,414557501,113556801	1053350611,1306287024,1346630621,1821025990,1104359090

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
CAH451358-01	Child	CAH	MEMORIAL HOSPITAL-SEMINOLE	Memorial Hospital Clinic West	1004 Hobbs Highway	Seminole	TX	Terminated
CAH451358-02	Child	CAH	MEMORIAL HOSPITAL-SEMINOLE	Rural Health Clinic	209 NW 8th Street	Seminole	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Change Request		CAH PHCY SRVCS DIV 16 13651 DUBLIN COURT Stafford, TX 77477	11/19/2024 1:48 PM
Contacts	Primary Contact	Update	Change Request	Everett, John CFO Seminole Hospital District 4327584945	Dabbs, Deborah Anne Compliance Officer Seminole Memorial Hospital 4327584868	11/19/2024 1:48 PM
Contacts	Primary Contact	Update	Recertification	Cottrell, Sharay Human Resources Director Seminole Hospital District 4327584986	Everett, John CFO Seminole Hospital District 4327584945	8/15/2024 9:12 AM
Details	Last Recertification Date	Update	Recertification	8/18/2023 12:02:15 PM	8/15/2024 9:12:19 AM	8/15/2024 9:12 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 2:02:52 PM	8/18/2023 12:02:15 PM	8/18/2023 12:02 PM
Contacts	Primary Contact	Update	Recertification	Gray, Larry CEO Seminole Memorial Hospital 4327584814	Cottrell, Sharay Human Resources Director Seminole Hospital District 4327584986	8/31/2022 2:02 PM
Details	Last Recertification Date	Update	Recertification	9/1/2021 4:26:45 PM	8/31/2022 2:02:52 PM	8/31/2022 2:02 PM
Contacts	Authorizing Official	Update	Profile Change Request	Garner, Maegen CCOO Seminole Memorial Hospital 4327584735	Garner, Maegen Interim CEO Seminole Memorial Hospital 4327584814	8/29/2022 6:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/8/2021 3:26 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		414557501	11/8/2021 3:26 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	11/8/2021 3:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1104359090	11/8/2021 3:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	11/8/2021 3:26 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 2:59:09 PM	9/1/2021 4:26:45 PM	9/1/2021 4:26 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1821025990 ( )		8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346630621 ( )		8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1306287024 ( )		8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053350611	8/21/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1306287024	8/21/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346630621	8/21/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1821025990	8/21/2020 2:59 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/21/2020 2:59 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1053350611 ( )		8/21/2020 2:59 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 8:08:38 PM	8/21/2020 2:59:09 PM	8/21/2020 2:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2020 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		402788001	3/25/2020 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/25/2020 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2020 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		402473901	3/25/2020 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/25/2020 3:33 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	018955702 (TX)		3/25/2020 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346630621	3/25/2020 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1306287024	3/25/2020 3:33 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598831745 ( )		3/25/2020 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/2/2020 1:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0941213-03	3/2/2020 1:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/2/2020 1:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1821025990	3/2/2020 1:03 PM
Contacts	Primary Contact	Update	Change Request	Adams, Joan CNO Seminole Memorial Hospital 4327584845	Gray, Larry CEO Seminole Memorial Hospital 4327584814	10/24/2019 12:30 PM
Contacts	Authorizing Official	Update	Profile Change Request	Garner, Maegen Chief Medical Informatics Seminole Memorial Hospital 4327584735	Garner, Maegen CCOO Seminole Memorial Hospital 4327584735	10/24/2019 12:13 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	322944501 (TX)		8/21/2019 8:08 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	354634301 (TX)		8/21/2019 8:08 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	178909109 (TX)		8/21/2019 8:08 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	358877401 (TX)		8/21/2019 8:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1104147990 ( )		8/21/2019 8:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1467823187 ( )		8/21/2019 8:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1235107657 ( )		8/21/2019 8:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1760725204 ( )		8/21/2019 8:08 PM
Contacts	Primary Contact	Update	Recertification	Garner, Maegen Chief Medical Informatics Seminole Memorial Hospital 4327584735	Adams, Joan CNO Seminole Memorial Hospital 4327584845	8/21/2019 8:08 PM
Details	Last Recertification Date	Update	Recertification		8/21/2019 8:08:38 PM	8/21/2019 8:08 PM
Contacts	Authorizing Official	Update	Change Request	Wright, Laban Joseph CEO Seminole Memorial Hospital 4327584814-4327584814	Garner, Maegen Chief Medical Informatics Seminole Memorial Hospital 4327584735	6/20/2019 12:34 PM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Signed By	Update	Reinstatement	Briscoe, Betsy CEO 4327584898	Wright, Laban Joseph CEO Seminole Memorial Hospital 4327584814-4327584814	1/28/2019 9:58 AM
Contacts	Primary Contact	Update	Reinstatement	Neel, Amy Business Office Manager Seminole Memorial Hospital 4327584862	Garner, Maegen Chief Medical Informatics Seminole Memorial Hospital 4327584735	1/28/2019 9:58 AM
Details	Entity Name	Update	Reinstatement	Seminole Hospital District DBA Memorial Hospital	MEMORIAL HOSPITAL-SEMINOLE	1/28/2019 9:58 AM
Dates	Participating Approval Date	Update	Reinstatement		1/28/2019 9:58:16 AM	1/28/2019 9:58 AM
Details	State	Update	Reinstatement	Pending	Approved	1/28/2019 9:58 AM
Dates	Signed By Date	Update	Reinstatement	10/15/2015 12:00:00 AM	1/15/2019 4:57:24 PM	1/28/2019 9:58 AM
Dates	Start Date	Update	Reinstatement		4/1/2019 12:00:00 AM	1/28/2019 9:58 AM
Contacts	Authorizing Official	Update	Reinstatement	Parrish, James Gordon CEO Seminole Memorial Hospital 4327584814	Wright, Laban Joseph CEO Seminole Memorial Hospital 4327584814-4327584814	1/28/2019 9:36 AM
Details	Comments Public	Insert	Reinstatement		Participating from effective date 01/01/2016) ) until terminated effective date (10/1/2018), reinstatement effective date (04/01/2019)	1/16/2019 7:50 AM
Details	Last Recertification Date	Update	Reinstatement	8/22/2018 2:37:22 PM		1/14/2019 3:46 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	9/30/2018 12:00:00 AM		1/14/2019 3:46 PM
Dates	Participating Approval Date	Update	Reinstatement	11/9/2015 12:00:00 AM		1/14/2019 3:46 PM
Details	State	Update	Reinstatement	Terminated	Pending	1/14/2019 3:46 PM
Dates	Registration Date	Update	Reinstatement	10/15/2015 12:00:00 AM	1/14/2019 3:46:22 PM	1/14/2019 3:46 PM
Dates	Start Date	Update	Reinstatement	1/1/2016 12:00:00 AM		1/14/2019 3:46 PM
Terminations	Termination Date	Update	Reinstatement	10/1/2018 12:00:00 AM		1/14/2019 3:46 PM
Terminations	Termination Effective Date	Update	Reinstatement	10/1/2018 12:00:00 AM		1/14/2019 3:46 PM
Terminations	Termination Reason	Update	Reinstatement	Failure to recertify		1/14/2019 3:46 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		9/30/2018 12:00:00 AM	9/17/2018 3:48 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/17/2018 3:48 PM
Terminations	Termination Date	Update	Recertification		10/1/2018 12:00:00 AM	9/17/2018 3:48 PM
Terminations	Termination Effective Date	Update	Recertification		10/1/2018 12:00:00 AM	9/17/2018 3:48 PM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	9/17/2018 3:48 PM
Details	Last Recertification Date	Update	Recertification	12/1/2017 2:07:46 PM	8/22/2018 2:37:22 PM	8/22/2018 2:37 PM
Addresses	Main Address	Update	Change Request	311 NW 8th Street Seminole, TX 79360	209 NW 8th Street Seminole, TX 79360	4/4/2018 1:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/4/2018 1:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		178909109	4/4/2018 1:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	4/4/2018 1:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/4/2018 1:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		358877401	4/4/2018 1:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	4/4/2018 1:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235107657	4/4/2018 1:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1760725204	4/4/2018 1:30 PM
Contacts	Primary Contact	Update	Recertification	Arledge, Nick COO 4327584814	Neel, Amy Business Office Manager Seminole Memorial Hospital 4327584862	12/1/2017 2:07 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	12/1/2017 2:07:46 PM	12/1/2017 2:07 PM
Details	Entity Subname	Update	Recertification	Memorial Hospital Clinic South	Rural Health Clinic	12/1/2017 2:07 PM
Details	Entity Name	Update	Change Request	MEMORIAL HOSPITAL-SEMINOLE	Seminole Hospital District DBA Memorial Hospital	10/16/2017 10:40 AM
Contacts	Authorizing Official	Insert	AO Change Request		Parrish, James Gordon CEO Seminole Memorial Hospital 4327584814	10/13/2017 2:31 PM
Contacts	Signed By	Insert			Briscoe, Betsy CEO 4327584898	4/5/2017 2:45 PM
Addresses	Main Address	Insert			311 NW 8th Street Seminole, TX 79360	4/5/2017 2:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/5/2017 2:44 PM
Medicaid Billing	Medicaid: Number	Insert			354634301	4/5/2017 2:44 PM
Medicaid Billing	Medicaid: State	Insert			TX	4/5/2017 2:44 PM
Medicaid Billing	NPI: Number	Insert			1467823187	4/5/2017 2:44 PM
Contacts	Primary Contact	Update		Anderson, Traci Chief Financial Officer 4327584866	Arledge, Nick COO 4327584814	8/31/2016 9:27 AM
Details	Last Recertification Date	Update			8/31/2016 12:00:00 AM	8/31/2016 9:27 AM
Contacts	Primary Contact	Insert			Anderson, Traci Chief Financial Officer 4327584866	4/8/2016 12:35 PM
Dates	Participating Approval Date	Update			11/9/2015 12:00:00 AM	11/9/2015 5:51 PM
Details	State	Update		Pending	Active	11/9/2015 5:51 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/9/2015 5:51 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_56098	CAH451358-02	11/6/2015 2:19 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_56098	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: Number	Insert			113556801	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: State	Insert			TX	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: Number	Insert			322944501	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: State	Insert			TX	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: Number	Insert			018955702	10/15/2015 3:09 PM
Medicaid Billing	Medicaid: State	Insert			TX	10/15/2015 3:09 PM
Medicaid Billing	NPI: Number	Insert			1053350611	10/15/2015 3:09 PM
Medicaid Billing	NPI: Number	Insert			1104147990	10/15/2015 3:09 PM
Medicaid Billing	NPI: Number	Insert			1598831745	10/15/2015 3:09 PM
Details	Last Recertification Date	Insert				10/15/2015 3:09 PM
Details	Grant Number	Insert				10/15/2015 3:09 PM
Details	340B ID	Insert				10/15/2015 3:09 PM
Details	Is Authorizing Official EHB Data	Insert				10/15/2015 3:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/15/2015 3:09 PM
Details	Medicare Provider Number	Insert			451358	10/15/2015 3:09 PM
Details	Entity Name	Insert			MEMORIAL HOSPITAL-SEMINOLE	10/15/2015 3:09 PM
Details	Program Code	Insert			CAH	10/15/2015 3:09 PM
Details	Entity Subname	Insert			Memorial Hospital Clinic South	10/15/2015 3:09 PM
Dates	Participating Approval Date	Insert				10/15/2015 3:09 PM
Details	State	Insert			Pending	10/15/2015 3:09 PM
Dates	Registration Date	Insert			10/15/2015 12:00:00 AM	10/15/2015 3:09 PM
Dates	Signed By Date	Insert			10/15/2015 12:00:00 AM	10/15/2015 3:09 PM
Dates	Start Date	Insert				10/15/2015 3:09 PM
Terminations	Termination Comments	Insert				10/15/2015 3:09 PM
Terminations	Termination Date	Insert				10/15/2015 3:09 PM
Terminations	Termination Effective Date	Insert				10/15/2015 3:09 PM
Terminations	Termination Reason	Insert				10/15/2015 3:09 PM