| Addresses | Billing Address | Insert | Change Request | | Northwest Miss Regional Medical Center DBA Northwest Mississippi Regional Medical Center
PO BOX 1218
Clarksdale, MS 38614-1218 | 1/14/2025 7:56 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1740876382 (MS) | | 1/14/2025 7:56 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1275109027 (MS) | | 1/14/2025 7:56 AM |
| Contacts | Primary Contact | Update | Change Request | Mayhood, William
340B
NWMRMC
6626243463 | Griffin, Amanda
Pharmacy Manager
Northwest Mississippi Regional Medical Center
6627195949 | 1/14/2025 7:56 AM |
| Details | Entity Name | Update | Change Request | DELTA HEALTH SYSTEM/ DBA DELTA HEALTH-NORTHWEST REGIONAL | Northwest Miss Regional Medical Center DBA Northwest Mississippi Regional Medical Center | 1/14/2025 7:56 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1275217606 | 8/23/2024 11:00 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MS | 8/23/2024 11:00 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1598458515 | 8/23/2024 11:00 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MS | 8/23/2024 11:00 AM |
| Contacts | Primary Contact | Update | Recertification | Cole, Jamie
Pharmacy Operations Specialist
Delta Health-The Medical Center
6627252210 | Mayhood, William
340B
NWMRMC
6626243463 | 8/23/2024 11:00 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2023 6:34:17 AM | 8/23/2024 11:00:29 AM | 8/23/2024 11:00 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Till, Lorie Suzanne
Chief Executive Officer
Northwest Mississippi Regional Medical Center
6626243463 | Till, Lorie Suzanne
CEO
Northwest Mississippi Regional Medical Center
6626243463 | 1/9/2024 8:20 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Benzing, Janet
Chief Administrative Officer
Delta Health System
6626243401 | Till, Lorie Suzanne
Chief Executive Officer
Northwest Mississippi Regional Medical Center
6626243463 | 11/27/2023 7:20 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2022 2:02:02 PM | 8/30/2023 6:34:17 AM | 8/30/2023 6:34 AM |
| Contacts | Primary Contact | Update | Change Request | Gilbert, Kasie
340B Coordinator/Clinical Data Analyst
Delta Health System
6627254486 | Cole, Jamie
Pharmacy Operations Specialist
Delta Health-The Medical Center
6627252210 | 1/17/2023 7:01 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 4:56:17 PM | 8/25/2022 2:02:02 PM | 8/25/2022 2:02 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1275109027 | 11/10/2021 11:55 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MS | 11/10/2021 11:55 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/30/2021 4:56:17 PM | 8/30/2021 4:56 PM |
| Details | Entity Name | Update | Change Request | NORTHWEST MS REG. MED. CENTER | DELTA HEALTH SYSTEM/ DBA DELTA HEALTH-NORTHWEST REGIONAL | 6/21/2021 6:36 AM |
| Details | State | Update | OPA Edit | Approved | Active | 6/17/2021 7:30 AM |
| Dates | Start Date | Update | OPA Edit | 7/1/2021 12:00:00 AM | 6/16/2021 12:00:00 AM | 6/17/2021 7:30 AM |
| Medicaid Billing | NPI: Number | Insert | Reinstatement | | 1740876382 | 6/17/2021 7:20 AM |
| Medicaid Billing | NPI: State | Insert | Reinstatement | | MS | 6/17/2021 7:20 AM |
| Medicaid Billing | NPI: Number | Delete | Reinstatement | 1386178721 ( ) | | 6/17/2021 7:20 AM |
| Contacts | Primary Contact | Update | Reinstatement | Scott, Lisa Price
Director of Reimbursement
Curae Health
8652822449 | Gilbert, Kasie
340B Coordinator/Clinical Data Analyst
Delta Health System
6627254486 | 6/17/2021 7:20 AM |
| Contacts | Authorizing Official | Update | Reinstatement | Brown, Tim
Chief Financial Officer
Curae Health
8658889359 | Benzing, Janet
Chief Administrative Officer
Delta Health System
6626243401 | 6/17/2021 7:20 AM |
| Contacts | Signed By | Update | Reinstatement | Brown, Tim
Chief Financial Officer
Curae Health
8658889359 | Benzing, Janet
Chief Administrative Officer
Delta Health System
6626243401 | 6/17/2021 7:20 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 9/30/2019 12:00:00 AM | | 6/17/2021 7:20 AM |
| Details | Entity Name | Update | Reinstatement | NORTHWEST MS MEDICAL CENTER | NORTHWEST MS REG. MED. CENTER | 6/17/2021 7:20 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 7/25/2018 12:22:23 PM | 6/17/2021 7:20:22 AM | 6/17/2021 7:20 AM |
| Details | State | Update | Reinstatement | Terminated | Approved | 6/17/2021 7:20 AM |
| Dates | Registration Date | Update | Reinstatement | 7/2/2018 3:13:03 PM | 4/6/2021 10:19:31 AM | 6/17/2021 7:20 AM |
| Dates | Signed By Date | Update | Reinstatement | 7/2/2018 4:43:37 PM | 6/16/2021 2:47:13 PM | 6/17/2021 7:20 AM |
| Dates | Start Date | Update | Reinstatement | 10/1/2018 12:00:00 AM | 7/1/2021 12:00:00 AM | 6/17/2021 7:20 AM |
| Terminations | Termination Date | Update | Reinstatement | 10/1/2019 12:00:00 AM | | 6/17/2021 7:20 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 9/30/2019 12:00:00 AM | | 6/17/2021 7:20 AM |
| Terminations | Termination Reason | Update | Reinstatement | Failure to recertify | | 6/17/2021 7:20 AM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 10/1/2018; Terminated 10/1/2019; Reinstated 6/16/2021. | 6/16/2021 3:04 PM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 10/1/2018; Terminated 10/1/2019; Reinstated 7/1/2021. | 6/3/2021 4:18 PM |
| Details | State | Update | | To Be Terminated | Terminated | 10/1/2019 12:05 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 9/30/2019 12:00:00 AM | 9/18/2019 3:02 PM |
| Details | State | Update | Recertification | Active | To Be Terminated | 9/18/2019 3:02 PM |
| Terminations | Termination Date | Update | Recertification | | 10/1/2019 12:00:00 AM | 9/18/2019 3:02 PM |
| Terminations | Termination Effective Date | Update | Recertification | | 9/30/2019 12:00:00 AM | 9/18/2019 3:02 PM |
| Terminations | Termination Reason | Update | Recertification | | Failure to recertify | 9/18/2019 3:02 PM |
| Details | Entity Name | Update | Change Request | NORTHWEST MS REG. MED. CENTER | NORTHWEST MS MEDICAL CENTER | 10/23/2018 9:48 AM |
| Details | State | Update | | Approved | Active | 10/1/2018 12:05 AM |
| Contacts | Signed By | Insert | New Registration | | Brown, Tim
Chief Financial Officer
Curae Health
8658889359 | 7/25/2018 12:22 PM |
| Details | 340B ID | Update | New Registration | | DSH250042 | 7/25/2018 12:22 PM |
| Dates | Participating Approval Date | Update | New Registration | | 7/25/2018 12:22:23 PM | 7/25/2018 12:22 PM |
| Details | State | Update | New Registration | Pending | Approved | 7/25/2018 12:22 PM |
| Dates | Signed By Date | Update | New Registration | | 7/2/2018 4:43:37 PM | 7/25/2018 12:22 PM |
| Dates | Start Date | Update | New Registration | | 10/1/2018 12:00:00 AM | 7/25/2018 12:22 PM |
| Addresses | Main Address | Insert | New Registration | |
1970 HOSPITAL DRIVE
CLARKSDALE, MS 38614 | 7/2/2018 3:13 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 7/2/2018 3:13 PM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 00220380 | 7/2/2018 3:13 PM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | MS | 7/2/2018 3:13 PM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1386178721 | 7/2/2018 3:13 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Brown, Tim
Chief Financial Officer
Curae Health
8658889359 | 7/2/2018 3:13 PM |
| Contacts | Primary Contact | Insert | New Registration | | Scott, Lisa Price
Director of Reimbursement
Curae Health
8652822449 | 7/2/2018 3:13 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Details | Grant Number | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Details | 340B ID | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 250042 | 7/2/2018 3:13 PM |
| Details | Entity Name | Insert | New Registration | | NORTHWEST MS REG. MED. CENTER | 7/2/2018 3:13 PM |
| Details | Program Code | Insert | New Registration | | DSH | 7/2/2018 3:13 PM |
| Details | Entity Subname | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Details | State | Insert | New Registration | | Pending | 7/2/2018 3:13 PM |
| Dates | Registration Date | Insert | New Registration | | 7/2/2018 3:13:03 PM | 7/2/2018 3:13 PM |
| Dates | Signed By Date | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Dates | Start Date | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Terminations | Termination Date | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 7/2/2018 3:13 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 7/2/2018 3:13 PM |