Covered Entity Details

CAH451386-06 Moore County Hospital District d/b/a Memorial Hospital (Active) - information as of 4/24/2025 10:13:53 PM

Main Details

Name

Moore County Hospital District d/b/a Memorial Hospital

Subdivision Name

MOORE COUNTY FOOT & ANKLE - Podiatry

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH451386-06

Medicare Provider Number

451386

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

2/12/2018

Participating Start Date

4/1/2018

Participating Approval Date

3/6/2018

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Moore County Hospital District
JEFF Ray TURNER, CEO
(806) 935-7171

Primary Contact

Moore County Hospital District
Ashleigh Dozier Wiswell, Chief Operations Officer
(806) 934-7802

Addresses

Street Address

212 S BLISS AVE
DUMAS, TX 79029-3806

Billing Address

Moore County Hospital District dba Memorial Hospital
224 E. 2nd St.
Dumas, TX 79029

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
TX	081954202	1700991700

Shipping Addresses

Shipping Address 1

Moore County Hospital District dba Memorial Hospital
224 E. 2nd Steet
Dumas, TX 79029

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
CAH451386-01	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	Moore County General Surgery - General surgery	1405 E 1ST ST	Dumas	TX	Active
CAH451386-02	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	Memorial Hospice - Hospice	209 S. Bliss	Dumas	TX	Active
CAH451386-03	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	MOORE COUNTY BONE & JOINT- Orthopedic	1515 E 1ST ST	DUMAS	TX	Active
CAH451386-04	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	Moore County Family Health Clinic - Rural Health Clinic-Primary Care	110 S. Bliss	Dumas	TX	Active
CAH451386-05	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	MOORE COUNTY OBSTETRICS &GYNECOLOGY - Obstetrics and Gynecology	1515 E 1ST ST	DUMAS	TX	Active
CAH451386-06	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	MOORE COUNTY FOOT & ANKLE - Podiatry	212 S BLISS AVE	DUMAS	TX	Active
CAH451386-07	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	Moore County Internal Medicine - Internal Medicine	1405 E. 1st St.	Dumas	TX	Active
CAH451386-08	Child	CAH	Moore County Hospital District d/b/a Memorial Hospital	ADULT MEDICINE CLINIC - Internal Medicine	224 S BLISS AVE	DUMAS	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/26/2023 1:05:00 PM	8/14/2024 4:18:53 PM	8/14/2024 4:18 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 4:08:13 PM	8/26/2023 1:05:00 PM	8/26/2023 1:05 PM
Details	Entity Subname	Update	Recertification	MOORE COUNTY FOOT & ANKLES - Podiatry	MOORE COUNTY FOOT & ANKLE - Podiatry	8/26/2023 1:05 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 11:04:35 AM	8/31/2022 4:08:13 PM	8/31/2022 4:08 PM
Addresses	Main Address	Update	Change Request	222 S BLISS AVE DUMAS, TX 79029-3806	212 S BLISS AVE DUMAS, TX 79029-3806	11/23/2021 11:16 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 12:08:52 PM	8/27/2021 11:04:35 AM	8/27/2021 11:04 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700991700	9/2/2020 12:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/2/2020 12:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1700991700 ( )		9/2/2020 12:08 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 3:29:57 PM	9/2/2020 12:08:52 PM	9/2/2020 12:08 PM
Details	Last Recertification Date	Update	Recertification	8/20/2018 10:24:57 AM	9/3/2019 3:29:57 PM	9/3/2019 3:29 PM
Contacts	Authorizing Official	Update	Reinstatement	TURNER, JEFF CEO Moore County Hospital District 8069357171	TURNER, JEFF Ray CEO Moore County Hospital District 8069357171	1/8/2019 4:04 PM
Contacts	Signed By	Update	Reinstatement	TURNER, JEFF CEO Moore County Hospital District 8069357171	TURNER, JEFF Ray CEO Moore County Hospital District 8069357171	1/8/2019 4:04 PM
Contacts	Primary Contact	Update	Reinstatement	Wiswell, Ashleigh Chief Operations Officer Moore County Hospital District 8069347802	Wiswell, Ashleigh Dozier Chief Operations Officer Moore County Hospital District 8069347802	1/8/2019 4:04 PM
Details	Last Recertification Date	Update	Recertification		8/20/2018 10:24:57 AM	8/20/2018 10:24 AM
Details	State	Update		Approved	Active	4/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		TURNER, JEFF CEO Moore County Hospital District 8069357171	3/6/2018 4:35 PM
Details	340B ID	Update	New Registration		CAH451386-06	3/6/2018 4:35 PM
Details	Entity Subname	Update	New Registration	MOORE COUNTY FOOT & ANKLES	MOORE COUNTY FOOT & ANKLES - Podiatry	3/6/2018 4:35 PM
Dates	Participating Approval Date	Update	New Registration		3/6/2018 4:35:35 PM	3/6/2018 4:35 PM
Details	State	Update	New Registration	Pending	Approved	3/6/2018 4:35 PM
Dates	Signed By Date	Update	New Registration		3/5/2018 3:48:00 PM	3/6/2018 4:35 PM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	3/6/2018 4:35 PM
Addresses	Main Address	Insert	New Registration		222 S BLISS AVE DUMAS, TX 79029-3806	2/12/2018 4:41 PM
Addresses	Billing Address	Insert	New Registration		Moore County Hospital District dba Memorial Hospital 224 E. 2nd St. Dumas, TX 79029	2/12/2018 4:41 PM
Addresses	Shipping Address	Insert	New Registration		Moore County Hospital District dba Memorial Hospital 224 E. 2nd Steet Dumas, TX 79029	2/12/2018 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	2/12/2018 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		081954202	2/12/2018 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	2/12/2018 4:41 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700991700	2/12/2018 4:41 PM
Contacts	Authorizing Official	Insert	New Registration		TURNER, JEFF CEO Moore County Hospital District 8069357171	2/12/2018 4:41 PM
Contacts	Primary Contact	Insert	New Registration		Wiswell, Ashleigh Chief Operations Officer Moore County Hospital District 8069347802	2/12/2018 4:41 PM
Details	Last Recertification Date	Insert	New Registration			2/12/2018 4:41 PM
Details	Grant Number	Insert	New Registration			2/12/2018 4:41 PM
Details	340B ID	Insert	New Registration			2/12/2018 4:41 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			2/12/2018 4:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			2/12/2018 4:41 PM
Details	Medicare Provider Number	Insert	New Registration		451386	2/12/2018 4:41 PM
Details	Entity Name	Insert	New Registration		Moore County Hospital District d/b/a Memorial Hospital	2/12/2018 4:41 PM
Details	Program Code	Insert	New Registration		CAH	2/12/2018 4:41 PM
Details	Entity Subname	Insert	New Registration		MOORE COUNTY FOOT & ANKLES	2/12/2018 4:41 PM
Dates	Participating Approval Date	Insert	New Registration			2/12/2018 4:41 PM
Details	State	Insert	New Registration		Pending	2/12/2018 4:41 PM
Dates	Registration Date	Insert	New Registration		2/12/2018 4:41:48 PM	2/12/2018 4:41 PM
Dates	Signed By Date	Insert	New Registration			2/12/2018 4:41 PM
Dates	Start Date	Insert	New Registration			2/12/2018 4:41 PM
Terminations	Termination Comments	Insert	New Registration			2/12/2018 4:41 PM
Terminations	Termination Date	Insert	New Registration			2/12/2018 4:41 PM
Terminations	Termination Effective Date	Insert	New Registration			2/12/2018 4:41 PM
Terminations	Termination Reason	Insert	New Registration			2/12/2018 4:41 PM