Covered Entity Details

CAH111331-04 MITCHELL COUNTY HOSPITAL (Active) - information as of 5/11/2025 11:27:05 PM

Main Details

Name

MITCHELL COUNTY HOSPITAL

Subdivision Name

ARCHBOLD PRIMARY CARE PELHAM

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH111331-04

Medicare Provider Number

111331

Outpatient Facility Provider Number

118544

Additional Details

Current Program Status

Active

Registration Date

1/4/2016

Participating Start Date

4/1/2016

Participating Approval Date

2/29/2016

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

John D. Archbold Memorial Hospital
Greg S. Hembree, CFO
(229) 228-2853

Primary Contact

John D. Archbold Memorial Hospital
Chris Newman, Vice President, Clinical and Support Services
(229) 228-2771

Addresses

Street Address

250 Blanton Street NE
Pelham, GA 31779-1138

Billing Address

Mitchell County Hospital
920 Cairo Road
Thomasville, GA 31792

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	003142002A	1881960151

Shipping Addresses

Shipping Address 1

Mitchell County Hospital
90 E Stephens Street
Camilla, GA 31730

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
CAH111331-01	Child	CAH	MITCHELL COUNTY HOSPITAL	ARCHBOLD PRIMARY CARE CAMILLA	259 US HWY 19 N	Camilla	GA	Active
CAH111331-02	Child	CAH	MITCHELL COUNTY HOSPITAL	ARCHBOLD PEDIATRICS CAMILLA	25 Perry Street	Camilla	GA	Active
CAH111331-03	Child	CAH	MITCHELL COUNTY HOSPITAL	ARCHBOLD THERAPY CAMILLA	99 E Broad Street	Camilla	GA	Active
CAH111331-04	Child	CAH	MITCHELL COUNTY HOSPITAL	ARCHBOLD PRIMARY CARE PELHAM	250 Blanton Street NE	Pelham	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Newman, Chris Vice President, Clinical Services John D. Archbold Memorial Hospital 2292282771	Newman, Chris Vice President, Clinical and Support Services John D. Archbold Memorial Hospital 2292282771	8/29/2024 3:39 PM
Details	Last Recertification Date	Update	Recertification	8/18/2023 2:52:58 PM	8/22/2024 4:53:46 PM	8/22/2024 4:53 PM
Addresses	Shipping Address	Insert	Recertification		Mitchell County Hospital 90 E Stephens Street Camilla, GA 31730	8/18/2023 2:52 PM
Addresses	Main Address	Update	Recertification	250 BLANTON ST. NE PELHAM, GA 31779-1138	250 Blanton Street NE Pelham, GA 31779-1138	8/18/2023 2:52 PM
Addresses	Shipping Address	Delete	Recertification	Mitchell County Hospital 90 Stephens Street Camilla, GA 31728		8/18/2023 2:52 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 5:25:04 PM	8/18/2023 2:52:58 PM	8/18/2023 2:52 PM
Details	Entity Subname	Update	Recertification	PELHAM PRIMARY CARE CLINIC	ARCHBOLD PRIMARY CARE PELHAM	8/18/2023 2:52 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 1:54:14 PM	9/7/2022 5:25:04 PM	9/7/2022 5:25 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 5:40:46 PM	8/27/2021 1:54:14 PM	8/27/2021 1:54 PM
Contacts	Primary Contact	Update	Profile Change Request	Newman, Chris Vice President, Ancillary Services John D. Archbold Memorial Hospital 2292282771	Newman, Chris Vice President, Clinical Services John D. Archbold Memorial Hospital 2292282771	2/17/2021 8:31 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1881960151	8/19/2020 5:40 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/19/2020 5:40 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1881960151 ( )		8/19/2020 5:40 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 12:29:23 PM	8/19/2020 5:40:46 PM	8/19/2020 5:40 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 10:23:51 AM	8/28/2019 12:29:23 PM	8/28/2019 12:29 PM
Addresses	Billing Address	Update	Change Request	Archbold Pelham Primary Care Clinic 900 Cairo Road Thomasville, GA 31792	Mitchell County Hospital 920 Cairo Road Thomasville, GA 31792	3/20/2019 10:02 AM
Details	Last Recertification Date	Update	Recertification	11/14/2017 11:32:06 AM	8/22/2018 10:23:51 AM	8/22/2018 10:23 AM
Contacts	Authorizing Official	Update	Profile Change Request	Hembree, Greg S. CFO John D. Archboold Memorial Hospital 2292282853	Hembree, Greg S. CFO John D. Archbold Memorial Hospital 2292282853	4/26/2018 6:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Newman, Chris Pharmacy Director John D. Archbold Memorial Hospital 2292282752	Newman, Chris Vice President, Ancillary Services John D. Archbold Memorial Hospital 2292282771	3/29/2018 9:50 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/14/2017 11:32:06 AM	11/14/2017 11:32 AM
Contacts	Authorizing Official	Update		Hembree, Greg S. CFO 2292282853	Hembree, Greg S. CFO John D. Archboold Memorial Hospital 2292282853	10/22/2017 1:10 PM
Contacts	Primary Contact	Update		Newman, Chris Pharmacy Director 2292282752	Newman, Chris Pharmacy Director John D. Archbold Memorial Hospital 2292282752	9/29/2017 9:39 AM
Contacts	Authorizing Official	Insert			Hembree, Greg S. CFO 2292282853	1/22/2017 3:05 PM
Contacts	Primary Contact	Insert			Newman, Chris Pharmacy Director 2292282752	1/22/2017 3:05 PM
Contacts	Signed By	Insert			HIGHTOWER, CHARLES D. CFO 2292282853	1/22/2017 3:05 PM
Addresses	Main Address	Insert			250 BLANTON ST. NE PELHAM, GA 31779-1138	1/22/2017 2:59 PM
Addresses	Billing Address	Insert			Archbold Pelham Primary Care Clinic 900 Cairo Road Thomasville, GA 31792	1/22/2017 2:59 PM
Addresses	Shipping Address	Insert			Mitchell County Hospital 90 Stephens Street Camilla, GA 31728	1/22/2017 2:59 PM
Details	Last Recertification Date	Update			8/18/2016 12:00:00 AM	8/18/2016 3:35 PM
Dates	Participating Approval Date	Update			2/29/2016 12:00:00 AM	2/29/2016 3:40 PM
Details	State	Update		Pending	Active	2/29/2016 3:40 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/29/2016 3:40 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_56469	CAH111331-04	1/5/2016 9:17 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_56469	1/4/2016 2:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/4/2016 2:47 PM
Medicaid Billing	Medicaid: Number	Insert			003142002A	1/4/2016 2:47 PM
Medicaid Billing	Medicaid: State	Insert			GA	1/4/2016 2:47 PM
Medicaid Billing	NPI: Number	Insert			1881960151	1/4/2016 2:47 PM
Details	Last Recertification Date	Insert				1/4/2016 2:47 PM
Details	Grant Number	Insert				1/4/2016 2:47 PM
Details	340B ID	Insert				1/4/2016 2:47 PM
Details	Is Authorizing Official EHB Data	Insert				1/4/2016 2:47 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/4/2016 2:47 PM
Details	Medicare Provider Number	Insert			111331	1/4/2016 2:47 PM
Details	Entity Name	Insert			MITCHELL COUNTY HOSPITAL	1/4/2016 2:47 PM
Details	Program Code	Insert			CAH	1/4/2016 2:47 PM
Details	Entity Subname	Insert			PELHAM PRIMARY CARE CLINIC	1/4/2016 2:47 PM
Dates	Participating Approval Date	Insert				1/4/2016 2:47 PM
Details	State	Insert			Pending	1/4/2016 2:47 PM
Dates	Registration Date	Insert			1/4/2016 12:00:00 AM	1/4/2016 2:47 PM
Dates	Signed By Date	Insert			1/4/2016 12:00:00 AM	1/4/2016 2:47 PM
Dates	Start Date	Insert				1/4/2016 2:47 PM
Terminations	Termination Comments	Insert				1/4/2016 2:47 PM
Terminations	Termination Date	Insert				1/4/2016 2:47 PM
Terminations	Termination Effective Date	Insert				1/4/2016 2:47 PM
Terminations	Termination Reason	Insert				1/4/2016 2:47 PM