Covered Entity Details

CAH251308-02 PONTOTOC HEALTH SERVICES (Active) - information as of 6/7/2025 4:46:09 AM

Main Details

Name

PONTOTOC HEALTH SERVICES

Subdivision Name

PONTOTOC HEALTH SERVICES - Rural Health Clinic Pontotoc

Type

Critical Access Hospital

Rural

340B ID

CAH251308-02

Medicare Provider Number

251308

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2016

Participating Start Date

7/1/2016

Participating Approval Date

5/2/2016

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

North Mississippi Medical Center
BRUCE J. TOPPIN, GENERAL COUNSEL, PRIVACY OFFICER & COPORATE SECRETARY
(662) 377-4229

Primary Contact

North Mississippi Medical Center
Patti Hawkins, Director
(662) 377-4731

Addresses

Street Address

345 HWY 15 N
PONTOTOC MEDICAL
PONTOTOC, MS 38863-3311

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	00020096,09583866	1538576772,1821103516

Shipping Addresses

Shipping Address 1

NMMC- SPD Logisitics Center
518 Weaver Drive
Tupelo, MS 38804

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
CAH251308-01	Child	CAH	PONTOTOC HEALTH SERVICES	PONTOTOC HEALTH SERVICES,Inc- Children's Clinic Ecru	202 MAIN STREET	ECRU	MS	Active
CAH251308-02	Child	CAH	PONTOTOC HEALTH SERVICES	PONTOTOC HEALTH SERVICES - Rural Health Clinic Pontotoc	345 HWY 15 N	PONTOTOC	MS	Active
CAH251308-03	Child	CAH	PONTOTOC HEALTH SERVICES	PONTOTOC HEALTH SERVICES - Rural Health Clinic New Albany	400 DOCTOR'S DRIVE	NEW ALBANY	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/30/2023 9:02:15 PM	9/6/2024 1:50:40 PM	9/6/2024 1:50 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 6:47:02 PM	8/30/2023 9:02:15 PM	8/30/2023 9:02 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 5:51:18 PM	9/8/2022 6:47:02 PM	9/8/2022 6:47 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 3:02:06 PM	9/9/2021 5:51:18 PM	9/9/2021 5:51 PM
Medicaid Billing	NPI: State	Update	Recertification		MS	9/10/2020 3:02 PM
Medicaid Billing	NPI: State	Update	Recertification		MS	9/10/2020 3:02 PM
Details	Last Recertification Date	Update	Recertification	9/12/2019 2:53:19 PM	9/10/2020 3:02:06 PM	9/10/2020 3:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1821103516	9/12/2019 2:53 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 11:15:16 AM	9/12/2019 2:53:19 PM	9/12/2019 2:53 PM
Details	Last Recertification Date	Update	Recertification	11/16/2017 10:42:12 AM	8/30/2018 11:15:16 AM	8/30/2018 11:15 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/16/2017 10:42:12 AM	11/16/2017 10:42 AM
Contacts	Authorizing Official	Insert	AO Change Request		TOPPIN, BRUCE J. GENERAL COUNSEL, PRIVACY OFFICER & COPORATE SECRETARY North Mississippi Medical Center 6623774229	11/13/2017 7:15 AM
Contacts	Primary Contact	Update		Hawkins, Patti Director 6623774731	Hawkins, Patti Director North Mississippi Medical Center 6623774731	10/18/2017 11:51 AM
Contacts	Primary Contact	Insert			Hawkins, Patti Director 6623774731	7/24/2017 6:09 PM
Contacts	Signed By	Insert			Toppin, Bruce Secretary, NMMC 6623774229	7/24/2017 6:09 PM
Addresses	Main Address	Insert			345 HWY 15 N PONTOTOC MEDICAL PONTOTOC, MS 38863-3311	11/16/2016 8:53 AM
Addresses	Shipping Address	Insert			NMMC- SPD Logisitics Center 518 Weaver Drive Tupelo, MS 38804	11/16/2016 8:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/18/2016 11:13 AM
Medicaid Billing	Medicaid: Number	Insert			09583866	8/18/2016 11:13 AM
Medicaid Billing	Medicaid: State	Insert			MS	8/18/2016 11:13 AM
Medicaid Billing	NPI: Number	Insert			1538576772	8/18/2016 11:13 AM
Details	Last Recertification Date	Update			8/18/2016 12:00:00 AM	8/18/2016 11:13 AM
Dates	Participating Approval Date	Update			5/2/2016 12:00:00 AM	5/2/2016 3:04 PM
Details	State	Update		Pending	Active	5/2/2016 3:04 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	5/2/2016 3:04 PM
Details	Entity Subname	Update		PONTOTOC HEALTH SERVICES	PONTOTOC HEALTH SERVICES - Rural Health Clinic Pontotoc	5/2/2016 9:03 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_60218	CAH251308-02	4/25/2016 12:46 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_60218	4/14/2016 10:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2016 10:41 AM
Medicaid Billing	Medicaid: Number	Insert			00020096	4/14/2016 10:41 AM
Medicaid Billing	Medicaid: State	Insert			MS	4/14/2016 10:41 AM
Details	Last Recertification Date	Insert				4/14/2016 10:41 AM
Details	Grant Number	Insert				4/14/2016 10:41 AM
Details	340B ID	Insert				4/14/2016 10:41 AM
Details	Is Authorizing Official EHB Data	Insert				4/14/2016 10:41 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2016 10:41 AM
Details	Medicare Provider Number	Insert			251308	4/14/2016 10:41 AM
Details	Entity Name	Insert			PONTOTOC HEALTH SERVICES	4/14/2016 10:41 AM
Details	Program Code	Insert			CAH	4/14/2016 10:41 AM
Details	Entity Subname	Insert			PONTOTOC HEALTH SERVICES	4/14/2016 10:41 AM
Dates	Participating Approval Date	Insert				4/14/2016 10:41 AM
Details	State	Insert			Pending	4/14/2016 10:41 AM
Dates	Registration Date	Insert			4/14/2016 12:00:00 AM	4/14/2016 10:41 AM
Dates	Signed By Date	Insert			4/14/2016 12:00:00 AM	4/14/2016 10:41 AM
Dates	Start Date	Insert				4/14/2016 10:41 AM
Terminations	Termination Comments	Insert				4/14/2016 10:41 AM
Terminations	Termination Date	Insert				4/14/2016 10:41 AM
Terminations	Termination Effective Date	Insert				4/14/2016 10:41 AM
Terminations	Termination Reason	Insert				4/14/2016 10:41 AM