Covered Entity Details

CAH251300-10 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL (Active) - information as of 4/29/2025 1:40:34 AM

Main Details

Name

INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

Subdivision Name

LACKEY PEDIATRIC CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH251300-10

Medicare Provider Number

251300

Outpatient Facility Provider Number

258608

Additional Details

Current Program Status

Active

Registration Date

1/15/2016

Participating Start Date

4/1/2016

Participating Approval Date

2/12/2016

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Lackey Memorial Hospital
sydney sawyer, ceo
(601) 469-4151 Ext: 301

Primary Contact

Lackey Memorial Hospital - Magee, MS
Carol Denton, Integrity Officer/Privacy & Security
(601) 209-3483

Addresses

Street Address

1 Medical Lane
FOREST, MS 39074-8829

Billing Address

Independent Healthcare Management, Inc.
P O Box 1460
Magee, MS 39111-5501

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	00383208	1154670719

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
CAH251300-01	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Main Street Medical Clinic of Sebastopol	17509 Highway 21	Sebastapol	MS	Terminated
CAH251300-02	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Main Street Medical Clinic of Morton	347 South 4th Street	Morton	MS	Active
CAH251300-03	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Community Health Clinic	505 Airport Road	Forest	MS	Active
CAH251300-04	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Lackey Outpatient Behavioral Health of Forest	1084-A Highway 35 South	Forest	MS	Active
CAH251300-05	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Lackey Outpatient Behavioral Health of Carthage	105 Van Buren Street	Carthage	MS	Active
CAH251300-06	Child	CAH	SE LACKEY CAH AND NURSING HOME	Lackey Outpatient Behavioral Health of Pelahatchie	505 2nd Street	Pelathatchie	MS	Terminated
CAH251300-07	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Lackey Outpatient Behavioral Health of Philadelphia	220 Hospital Road	Philadelphia	MS	Active
CAH251300-08	Child	CAH	SE LACKEY CAH AND NURSING HOME	MAIN STREET MEDICAL CLINIC OF SEBAS	17509 HWY 21	SEBASTOPOL	MS	Terminated
CAH251300-09	Child	CAH	SE LACKEY CAH AND NURSING HOME	MAIN STREET MEDICAL CLINIC OF MORTON	347 SOUTH 4TH STREET	MORTON	MS	Terminated
CAH251300-10	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	LACKEY PEDIATRIC CLINIC	1 Medical Lane	FOREST	MS	Active
CAH251300-11	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT I - Newton Family and Pediatric Clinic	NEWTON FAMILY AND PEDIATRIC CLINIC	NEWTON	MS	Active
CAH251300-12	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT I - Forest Family Medical Clinic	1 MEDICAL LN STE B	FOREST	MS	Terminated
CAH251300-13	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT, INC - 149 Pediatric and Family	376 Simpson Hwy 149, Suite 600	Magee	MS	Active
CAH251300-14	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Specialty Clinic - Multispecialty clinic services	505 Airport Road	Forest	MS	Active
CAH251300-15	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT I - 35 South Family Medical	342 MAGNOLIA DR	RALEIGH	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/8/2023 11:55:14 AM	8/28/2024 5:18:22 PM	8/28/2024 5:18 PM
Addresses	Main Address	Update	Change Request	1129 HWY 35 SOUTH SUITE1 FOREST, MS 39074-8829	1 Medical Lane FOREST, MS 39074-8829	2/13/2024 6:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2023 11:55 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00383208	9/8/2023 11:55 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/8/2023 11:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154670719	9/8/2023 11:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/8/2023 11:55 AM
Details	Last Recertification Date	Update	Recertification	9/19/2022 2:49:35 PM	9/8/2023 11:55:14 AM	9/8/2023 11:55 AM
Addresses	Billing Address	Update	Change Request	Kanopy Healthcare Partners P O Box 1460 Magee, MS 39111-5501	Independent Healthcare Management, Inc. P O Box 1460 Magee, MS 39111-5501	7/6/2023 2:59 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 3:12:15 PM	9/19/2022 2:49:35 PM	9/19/2022 2:49 PM
Addresses	Billing Address	Update	Change Request	110 Pioneer Way - Magee, MS 39111-5501	Kanopy Healthcare Partners P O Box 1460 Magee, MS 39111-5501	2/22/2022 10:54 AM
Details	Last Recertification Date	Update	Recertification	8/18/2020 10:50:51 AM	8/24/2021 3:12:15 PM	8/24/2021 3:12 PM
Contacts	Primary Contact	Update	Group Change Request	Lott, Trent Pharmacist Lackey Memorial Hospital 6014694151-391	Denton, Carol Integrity Officer/Privacy & Security Lackey Memorial Hospital - Magee, MS 6012093483	7/12/2021 9:15 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 12:22:41 PM	8/18/2020 10:50:51 AM	8/18/2020 10:50 AM
Contacts	Authorizing Official	Update	Change Request	Sawyer, Sydney CEO Lackey Memorial Hopsital 6014694151-301	sawyer, sydney ceo Lackey Memorial Hospital 6014694151-301	12/30/2019 7:55 AM
Details	Last Recertification Date	Update	Recertification	9/4/2018 4:29:08 PM	9/9/2019 12:22:41 PM	9/9/2019 12:22 PM
Contacts	Primary Contact	Update	Profile Change Request	Lott, Trent Pharmacist Lackey MEmorial Hospital 6014694151-391	Lott, Trent Pharmacist Lackey Memorial Hospital 6014694151-391	1/14/2019 12:23 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 10:48:07 AM	9/4/2018 4:29:08 PM	9/4/2018 4:29 PM
Details	Entity Name	Update	Recertification	SE LACKEY CAH AND NURSING HOME	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	12/5/2017 10:54 AM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	12/5/2017 10:48:07 AM	12/5/2017 10:48 AM
Contacts	Authorizing Official	Update	New Registration	Sawyer, Sydney CEO 6014694151-301	Sawyer, Sydney CEO Lackey Memorial Hopsital 6014694151-301	10/13/2017 2:45 PM
Contacts	Primary Contact	Update		Lott, Trent Pharmacist 6014694151	Lott, Trent Pharmacist Lackey MEmorial Hospital 6014694151-391	9/29/2017 10:28 AM
Contacts	Signed By	Insert			McNulty III, Joseph S. President 6018496440	8/8/2017 3:13 PM
Contacts	Authorizing Official	Insert			Sawyer, Sydney CEO 6014694151-301	4/7/2017 11:18 AM
Contacts	Primary Contact	Update		Ilgenfritz, Carter Corp. Dir. of Pharmacy Programs 6018496440-339	Lott, Trent Pharmacist 6014694151	4/7/2017 11:18 AM
Addresses	Main Address	Insert			1129 HWY 35 SOUTH SUITE1 FOREST, MS 39074-8829	9/1/2016 8:24 AM
Details	Last Recertification Date	Update			9/1/2016 12:00:00 AM	9/1/2016 8:24 AM
Contacts	Primary Contact	Insert			Ilgenfritz, Carter Corp. Dir. of Pharmacy Programs 6018496440-339	8/26/2016 8:49 AM
Addresses	Billing Address	Insert			110 Pioneer Way - Magee, MS 39111-5501	2/12/2016 4:10 PM
Dates	Participating Approval Date	Update			2/12/2016 12:00:00 AM	2/12/2016 4:10 PM
Details	State	Update		Pending	Active	2/12/2016 4:10 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/12/2016 4:10 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_58320	CAH251300-10	2/3/2016 11:14 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_58320	1/15/2016 2:12 PM
Details	Last Recertification Date	Insert				1/15/2016 2:12 PM
Details	Grant Number	Insert				1/15/2016 2:12 PM
Details	340B ID	Insert				1/15/2016 2:12 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2016 2:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2016 2:12 PM
Details	Medicare Provider Number	Insert			251300	1/15/2016 2:12 PM
Details	Entity Name	Insert			SE LACKEY CAH AND NURSING HOME	1/15/2016 2:12 PM
Details	Program Code	Insert			CAH	1/15/2016 2:12 PM
Details	Entity Subname	Insert			LACKEY PEDIATRIC CLINIC	1/15/2016 2:12 PM
Dates	Participating Approval Date	Insert				1/15/2016 2:12 PM
Details	State	Insert			Pending	1/15/2016 2:12 PM
Dates	Registration Date	Insert			1/15/2016 12:00:00 AM	1/15/2016 2:12 PM
Dates	Signed By Date	Insert			1/15/2016 12:00:00 AM	1/15/2016 2:12 PM
Dates	Start Date	Insert				1/15/2016 2:12 PM
Terminations	Termination Comments	Insert				1/15/2016 2:12 PM
Terminations	Termination Date	Insert				1/15/2016 2:12 PM
Terminations	Termination Effective Date	Insert				1/15/2016 2:12 PM
Terminations	Termination Reason	Insert				1/15/2016 2:12 PM