Covered Entity Details

CAH251312-00 TYLER HOLMES MEMORIAL HOSPITAL (Active) - information as of 5/5/2025 10:04:46 PM

Main Details

Name

TYLER HOLMES MEMORIAL HOSPITAL

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH251312-00

Medicare Provider Number

251312

Additional Details

Current Program Status

Active

Registration Date

10/9/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/12/2017

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Tyler Holmes Memorial Hospital
Cori H Bailey, Administrator
(662) 283-4114 Ext: 6126

Primary Contact

Tyler Holmes Memorial Hospital
Jessica Mooney, Pharmacist
(662) 283-8287

Addresses

Street Address

409 Tyler Holmes Drive
WINONA, MS 38967

Billing Address

tyler holmes memorial hospital
409 Tyler Holmes Drive
Winona, MS 38967

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?
No

Shipping Addresses

Shipping Address 1

Tyler Holmes Memorial Hospital
409 Tyler Holmes Drive
Winona, MS 38967

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	ANDERSON'S PHARMACY	112 E MAIN ST	PO BOX 250	NORTH CARROLLTON	MS	38947-2000	07/07/2021	10/01/2021	10/01/2021
Contract Detail	GREENWOOD DRUGS	400 W PARK AVE		GREENWOOD	MS	38930-2904	01/06/2023	04/01/2023	04/01/2023
Contract Detail	HAMMOND'S PHARMACY	212 N APPLEGATE ST	P.O.BOX 309	WINONA	MS	38967-2124	04/16/2018	07/01/2018	04/16/2018
Contract Detail	SAV-MOR DRUGS AND GIFTS	1967 COMMERCE ST		GRENADA	MS	38901-5107	01/12/2023	04/01/2023	04/01/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/15/2022	07/19/2022	07/19/2022
Contract Detail	WAL-MART PHARMACY 10-0239	220 VETERANS MEMORIAL DRIVE		KOSCIUSKO	MS	39090	10/15/2024	01/01/2025	01/01/2025
Contract Detail	WAL-MART PHARMACY 10-0716	2202 HWY 82 WEST		GREENWOOD	MS	38930	10/15/2024	01/01/2025	01/01/2025
Contract Detail	WAL-MART PHARMACY 10-1074	1655 SUNSET DR		GRENADA	MS	38901	07/15/2022	07/19/2022	07/19/2022
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/15/2022	07/19/2022	07/19/2022
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/11/2023	07/01/2023	07/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/13/2023	01/01/2024	01/01/2024
Contract Detail	WINONA DRUGS	500 N APPLEGATE ST STE A		WINONA	MS	38967-1829	07/07/2021	10/01/2021	10/01/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH251312-01	Child	CAH	TYLER HOLMES MEMORIAL HOSPITAL	TYLER HOLMES MEMORIAL HOSPITAL - Family Medicine	WINONA FAMILY PRACTICE	WINONA	MS	Active
CAH251312-02	Child	CAH	TYLER HOLMES MEMORIAL HOSPITAL	TYLER HOLMES MEMORIAL HOSPITAL - Family Medicine	CROSSROADS FAMILY MEDICINE	WINONA	MS	Active
CAH251312-03	Child	CAH	TYLER HOLMES MEMORIAL HOSPITAL	TYLER HOLMES MEMORIAL HOSPITAL - Family Practice	502 GEORGE STREET	NORTH CARROLLTON	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 3:21:53 PM	8/16/2024 8:03:44 AM	8/16/2024 8:03 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 7:59:09 AM	8/16/2023 3:21:53 PM	8/16/2023 3:21 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 9:37:37 AM	8/25/2022 7:59:09 AM	8/25/2022 7:59 AM
Contacts	Primary Contact	Update	Profile Change Request	Mooney, Jessica Pharmacist Tyler Holmes Memorial Hospital 6622834114-8320	Mooney, Jessica Pharmacist Tyler Holmes Memorial Hospital 6622838287	4/25/2022 7:58 AM
Addresses	Main Address	Update	Change Request	TYLER HOLMES MEMORIAL HOSPITAL WINONA, MS 38967	409 Tyler Holmes Drive WINONA, MS 38967	9/23/2021 11:26 AM
Details	Last Recertification Date	Update	Recertification	8/28/2020 8:59:01 AM	8/27/2021 9:37:37 AM	8/27/2021 9:37 AM
Contacts	Primary Contact	Update	Recertification	Johnson, Robert Sean CEO Tyler Holmes Memorial Hospital 6622834114-6127	Mooney, Jessica Pharmacist Tyler Holmes Memorial Hospital 6622834114-8320	8/28/2020 8:59 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 1:54:50 PM	8/28/2020 8:59:01 AM	8/28/2020 8:59 AM
Contacts	Authorizing Official	Update	Profile Change Request	Bailey, Cori H Accounting Director / CFO Tyler Holmes Memorial Hospital 6622834114	Bailey, Cori H Administrator Tyler Holmes Memorial Hospital 6622834114-6126	8/28/2020 8:42 AM
Contacts	Signed By	Update	Profile Change Request	Bailey, Cori H Accounting Director / CFO Tyler Holmes Memorial Hospital 6622834114	Bailey, Cori H Administrator Tyler Holmes Memorial Hospital 6622834114-6126	8/28/2020 8:42 AM
Contacts	Primary Contact	Update	Recertification	Rutherford, Eddie D CEO Tyler Holmes Memorial Hospital 6622834114-6127	Johnson, Robert Sean CEO Tyler Holmes Memorial Hospital 6622834114-6127	8/29/2019 1:54 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 2:53:53 PM	8/29/2019 1:54:50 PM	8/29/2019 1:54 PM
Details	Last Recertification Date	Update	Recertification		8/21/2018 2:53:53 PM	8/21/2018 2:53 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Addresses	Billing Address	Insert	New Registration		Tyler Holmes Memorial Hospital 409 Tyler Holmes Drive Winona, MS 38967	10/12/2017 2:06 PM
Addresses	Shipping Address	Insert	New Registration		Tyler Holmes Memorial Hospital 409 Tyler Holmes Drive Winona, MS 38967	10/12/2017 2:06 PM
Contacts	Signed By	Insert	New Registration		Bailey, Cori H Accounting Director / CFO Tyler Holmes Memorial Hospital 6622834114	10/12/2017 2:06 PM
Details	340B ID	Update	New Registration		CAH251312-00	10/12/2017 2:06 PM
Dates	Participating Approval Date	Update	New Registration		10/12/2017 2:06:01 PM	10/12/2017 2:06 PM
Details	State	Update	New Registration	Pending	Approved	10/12/2017 2:06 PM
Dates	Signed By Date	Update	New Registration		10/10/2017 10:01:01 AM	10/12/2017 2:06 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/12/2017 2:06 PM
Addresses	Main Address	Insert	New Registration		TYLER HOLMES MEMORIAL HOSPITAL WINONA, MS 38967	10/9/2017 2:54 PM
Contacts	Authorizing Official	Insert	New Registration		Bailey, Cori H Accounting Director / CFO Tyler Holmes Memorial Hospital 6622834114	10/9/2017 2:54 PM
Contacts	Primary Contact	Insert	New Registration		Rutherford, Eddie D CEO Tyler Holmes Memorial Hospital 6622834114-6127	10/9/2017 2:54 PM
Details	Last Recertification Date	Insert	New Registration			10/9/2017 2:54 PM
Details	Grant Number	Insert	New Registration			10/9/2017 2:54 PM
Details	340B ID	Insert	New Registration			10/9/2017 2:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2017 2:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2017 2:54 PM
Details	Medicare Provider Number	Insert	New Registration		251312	10/9/2017 2:54 PM
Details	Entity Name	Insert	New Registration		TYLER HOLMES MEMORIAL HOSPITAL	10/9/2017 2:54 PM
Details	Program Code	Insert	New Registration		CAH	10/9/2017 2:54 PM
Details	Entity Subname	Insert	New Registration			10/9/2017 2:54 PM
Dates	Participating Approval Date	Insert	New Registration			10/9/2017 2:54 PM
Details	State	Insert	New Registration		Pending	10/9/2017 2:54 PM
Dates	Registration Date	Insert	New Registration		10/9/2017 2:54:48 PM	10/9/2017 2:54 PM
Dates	Signed By Date	Insert	New Registration			10/9/2017 2:54 PM
Dates	Start Date	Insert	New Registration			10/9/2017 2:54 PM
Terminations	Termination Comments	Insert	New Registration			10/9/2017 2:54 PM
Terminations	Termination Date	Insert	New Registration			10/9/2017 2:54 PM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2017 2:54 PM
Terminations	Termination Reason	Insert	New Registration			10/9/2017 2:54 PM