Covered Entity Details

RRC010024-09 JACKSON HOSPITAL AND CLINIC INC (Terminated) - information as of 6/4/2025 12:06:16 PM

Main Details

Name

JACKSON HOSPITAL AND CLINIC INC

Subdivision Name

JACKSON HOSP & CLINIC INC PK RD - Pike Road Clinic Family Medicine

Type

Rural Referral Center

Rural

Yes

340B ID

RRC010024-09

Medicare Provider Number

010024

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/6/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/31/2017

Last Recertification Date

9/1/2022

Termination Date
Termination Reason

9/7/2022
Change of hospital entity type

Contacts

Authorizing Official

Jackson Hospital
Joe Riley, CEO
(334) 293-8809

Primary Contact

Jackson Hospital and Clinics
Thomas Hudson Cobb, Director of Pharmacy
(334) 293-8806

Addresses

Street Address

11123 CHANTILLY PWKY CT
M
PIKE ROAD, AL 36064-2880

Billing Address

Jackson Hosptial and Clinic
1725 Pine St
Montgomery, AL 36106

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
AL	hos0024h	1043262488

Shipping Addresses

Shipping Address 1

Jackson Hosptial and Clinic
1725 Pine St
Montgomery, AL 36106

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
RRC010024-01	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Hospital Wound Care Center	1801 Pine Street	Montgomery	AL	Terminated
RRC010024-02	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Hospital Sleep Disorders Clinic	1722 Pine St	Montgomery	AL	Terminated
RRC010024-03	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Imaging Center	1825 Park Place	Montgomery	AL	Terminated
RRC010024-04	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC VASCULAR SURGERY - Vascular Surgery	1758 PARK PLACE	MONTGOMERY	AL	Terminated
RRC010024-05	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON FAMILY MEDICINE PRATTVILLE - Family Medicine	701 MCQUEEN SMITH RD S	PRATTVILLE	AL	Terminated
RRC010024-06	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Dr. Seirafi - Gen Surgery	7201 Copperfield Drive	Montgomery	AL	Terminated
RRC010024-07	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic General Surgery - General Surgery	1722 Pine Street	Montgomery	AL	Terminated
RRC010024-08	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Family Medicine - Family Medicine	1801 Pine St	Montgomery	AL	Terminated
RRC010024-09	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON HOSP & CLINIC INC PK RD - Pike Road Clinic Family Medicine	11123 CHANTILLY PWKY CT	PIKE ROAD	AL	Terminated
RRC010024-10	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Urology - Urology	1722 Pine Street	Montgomery	AL	Terminated
RRC010024-11	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Internal Medicine - Internal Medicine	1801 Pine St	Montgomery	AL	Terminated
RRC010024-12	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Neurology - Neurology	1801 Pine St	Montgomery	AL	Terminated
RRC010024-13	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON OBSTETRICS & GYNECOLOGY - OBSTETRICS & GYNECOLOGY	1758 PARK PLACE	MONTGOMERY	AL	Terminated
RRC010024-14	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Endocrinology - Endocrinology	1801 Pine Street	Montgomery	AL	Terminated
RRC010024-15	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Cardiology - Cardiology	1758 Park Place	Montgomery	AL	Terminated
RRC010024-16	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON HOSPITAL AND CLINIC, INC. - Jackson Clinic Urology East	226 MITYLENE PARK DR	MONTGOMERY	AL	Terminated
RRC010024-17	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON FAMILY MED MIDTOWN - Family Medicine	4150 CARMICHAEL RD	MONTGOMERY	AL	Terminated
RRC010024-18	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic Gastroenterology - Gastroenterology	1722 Pine St	Montgomery	AL	Terminated
RRC010024-19	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	Jackson Clinic - Rheumatology - Rheumatology	1722 Pine st	montgomery	AL	Terminated
RRC010024-20	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	OP infusion Clinic - Outpatient infusions Clinic	1725 pine street	Montgomery	AL	Terminated
RRC010024-21	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC PRATTVILLE PRIMARY C - Primary Care	204 MEDICAL CENTER DR	PRATTVILLE	AL	Terminated
RRC010024-22	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC MULTISPECIALTY PRATT - Multispecialty Clinic	1840 E MAIN ST	PRATTVILLE	AL	Terminated
RRC010024-23	Child	RRC	JACKSON HOSPITAL AND CLINIC INC	JACKSON CLINIC DALRAIDA - Family Medicine	4035 ATLANTA HWY	MONTGOMERY	AL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Cobb, Thomas Hudson Director of Pharmacy Jackson Hospital and Clinics 3342938780	Cobb, Thomas Hudson Director of Pharmacy Jackson Hospital and Clinics 3342938806	7/23/2024 3:26 PM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Edit Termination Info	10/1/2022 12:00:00 AM	9/7/2022 12:00:00 AM	9/7/2022 10:51 AM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	9/7/2022 10:51 AM
Terminations	Termination Date	Update	OPA Edit Termination Info	10/1/2022 12:00:00 AM	9/7/2022 12:00:00 AM	9/7/2022 10:51 AM
Terminations	Termination Effective Date	Update	OPA Edit Termination Info	10/1/2022 12:00:00 AM	9/7/2022 12:00:00 AM	9/7/2022 10:51 AM
Terminations	Termination Reason	Update	OPA Edit Termination Info	Change of covered entity type	Change of hospital entity type	9/7/2022 10:51 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2022 12:00:00 AM	9/7/2022 8:06 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	9/7/2022 8:06 AM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2022 12:00:00 AM	9/7/2022 8:06 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2022 12:00:00 AM	9/7/2022 8:06 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	9/7/2022 8:06 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 1:19:56 PM	9/1/2022 2:12:45 PM	9/1/2022 2:12 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 12:51:40 PM	9/10/2021 1:19:56 PM	9/10/2021 1:19 PM
Medicaid Billing	NPI: State	Update	Recertification		AL	9/9/2020 12:51 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 6:30:00 PM	9/9/2020 12:51:40 PM	9/9/2020 12:51 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 12:41:25 PM	8/22/2019 6:30:00 PM	8/22/2019 6:30 PM
Contacts	Primary Contact	Update		Cobb, Thomas Director of Pharmacy Jackson Hospital and Clinics 3342938780	Cobb, Thomas Hudson Director of Pharmacy Jackson Hospital and Clinics 3342938780	10/10/2018 3:18 PM
Details	Last Recertification Date	Update	Recertification		8/16/2018 12:41:25 PM	8/16/2018 12:41 PM
Addresses	Main Address	Update	Change Request	11123 CHANTILLY PWKY CT PIKE ROAD, AL 36064-2880	11123 CHANTILLY PWKY CT M PIKE ROAD, AL 36064-2880	7/18/2018 3:06 PM
Addresses	Billing Address	Insert	Change Request		Jackson Hosptial and Clinic 1725 Pine St Montgomery, AL 36106	7/18/2018 3:06 PM
Addresses	Shipping Address	Insert	Change Request		Jackson Hosptial and Clinic 1725 Pine St Montgomery, AL 36106	7/18/2018 3:06 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Riley, Joe CEO Jackson Hospital 3342938809	10/31/2017 9:54 AM
Details	340B ID	Update	New Registration		RRC010024-09	10/31/2017 9:54 AM
Details	Entity Subname	Update	New Registration	JACKSON HOSP & CLINIC INC PK RD	JACKSON HOSP & CLINIC INC PK RD - Pike Road Clinic Family Medicine	10/31/2017 9:54 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2017 9:54:24 AM	10/31/2017 9:54 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2017 9:54 AM
Dates	Signed By Date	Update	New Registration		10/7/2017 11:36:55 AM	10/31/2017 9:54 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/31/2017 9:54 AM
Addresses	Main Address	Insert	New Registration		11123 CHANTILLY PWKY CT PIKE ROAD, AL 36064-2880	10/6/2017 10:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2017 10:02 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		hos0024h	10/6/2017 10:02 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	10/6/2017 10:02 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1043262488	10/6/2017 10:02 AM
Contacts	Authorizing Official	Insert	New Registration		Riley, Joe CEO Jackson Hospital 3342938809	10/6/2017 10:02 AM
Contacts	Primary Contact	Insert	New Registration		Cobb, Thomas Director of Pharmacy Jackson Hospital and Clinics 3342938780	10/6/2017 10:02 AM
Details	Last Recertification Date	Insert	New Registration			10/6/2017 10:02 AM
Details	Grant Number	Insert	New Registration			10/6/2017 10:02 AM
Details	340B ID	Insert	New Registration			10/6/2017 10:02 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/6/2017 10:02 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/6/2017 10:02 AM
Details	Medicare Provider Number	Insert	New Registration		010024	10/6/2017 10:02 AM
Details	Entity Name	Insert	New Registration		JACKSON HOSPITAL AND CLINIC INC	10/6/2017 10:02 AM
Details	Program Code	Insert	New Registration		RRC	10/6/2017 10:02 AM
Details	Entity Subname	Insert	New Registration		JACKSON HOSP & CLINIC INC PK RD	10/6/2017 10:02 AM
Dates	Participating Approval Date	Insert	New Registration			10/6/2017 10:02 AM
Details	State	Insert	New Registration		Pending	10/6/2017 10:02 AM
Dates	Registration Date	Insert	New Registration		10/6/2017 10:02:12 AM	10/6/2017 10:02 AM
Dates	Signed By Date	Insert	New Registration			10/6/2017 10:02 AM
Dates	Start Date	Insert	New Registration			10/6/2017 10:02 AM
Terminations	Termination Comments	Insert	New Registration			10/6/2017 10:02 AM
Terminations	Termination Date	Insert	New Registration			10/6/2017 10:02 AM
Terminations	Termination Effective Date	Insert	New Registration			10/6/2017 10:02 AM
Terminations	Termination Reason	Insert	New Registration			10/6/2017 10:02 AM