Covered Entity Details

DSH250001AG University of Mississippi Medical Center (Active) - information as of 5/11/2025 11:28:20 PM

Main Details

Name

University of Mississippi Medical Center

Subdivision Name

Pavilion Transplant Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH250001AG

Medicare Provider Number

250001

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/14/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/31/2019

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

University of MIssissippi Medical Center
Jeffrey Grimsley, CFO-Health System
(601) 815-6270

Primary Contact

University of Mississippi Medical Center
Kelsey H Raymer, Health System 340B Operations Director
(601) 984-2676

Addresses

Street Address

2500 North State Street
Suite H
Jackson, MS 39216

Billing Address

University of Mississippi Medical Center
Attn: Pharmacy
2500 North State Street
Jackson, MS 39216

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	HOS1149N	1154317527,1194930693,1477734689,1649419532,1932144342
AZ	372079	1154317527,1194930693,1477734689,1649419532,1932144342
CA	XHDP42759	1154317527,1194930693,1477734689,1649419532,1932144342
CO	23487232	1154317527,1194930693,1477734689,1649419532,1932144342
FL	022089500	1154317527,1194930693,1477734689,1649419532,1932144342
GA	000108776B	1154317527,1194930693,1477734689,1649419532,1932144342
IL	646008520001	1154317527,1194930693,1477734689,1649419532,1932144342
IN	200125970A	1154317527,1194930693,1477734689,1649419532,1932144342
KY	01430321	1154317527,1194930693,1477734689,1649419532,1932144342
LA	1731200	1154317527,1194930693,1477734689,1649419532,1932144342
NY	01691529	1154317527,1194930693,1477734689,1649419532,1932144342
OH	188845	1154317527,1194930693,1477734689,1649419532,1932144342
OK	100698520A	1154317527,1194930693,1477734689,1649419532,1932144342
OR	500691621	1154317527,1194930693,1477734689,1649419532,1932144342
SC	10473A	1154317527,1194930693,1477734689,1649419532,1932144342
TN	0250001	1154317527,1194930693,1477734689,1649419532,1932144342
TX	072271201	1154317527,1194930693,1477734689,1649419532,1932144342
WI	1154317527	1154317527,1194930693,1477734689,1649419532,1932144342
MS	000020149,000020256,000330385,006300271,009903368	1154317527,1649419532,1932144342,1194930693,1477734689
AR		1154317527,1194930693,1477734689,1649419532,1932144342
MO		1154317527,1194930693,1477734689,1649419532,1932144342

Shipping Addresses

Shipping Address 1

University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216

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
DSH250001AA	Child	DSH	University of Mississippi Medical Center	Cancer Institute-Radiation Oncology	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001AB	Child	DSH	University of Mississippi Medical Center	JMM Endocrinology	350 West Woodrow Wilson Avenue	Jackson	MS	Terminated
DSH250001AC	Child	DSH	University of Mississippi Medical Center	JMM Children's Clinic	350 West Woodrow Wilson Avenue	Jackson	MS	Terminated
DSH250001AD	Child	DSH	University of Mississippi Medical Center	Neurophysiology	2500 North State Street	Jackson	MS	Active
DSH250001AE	Child	DSH	University of Mississippi Medical Center	UH GI Lab	2500 North State Street	Jackson	MS	Active
DSH250001AF	Child	DSH	University of Mississippi Medical Center	Cancer Clinics - Cancer Clinics	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001AG	Child	DSH	University of Mississippi Medical Center	Pavilion Transplant Clinic	2500 North State Street	Jackson	MS	Active
DSH250001AH	Child	DSH	University of Mississippi Medical Center	UMMC GI Lab - Belhaven - Gastroenterology	1405 North State Street	Jackson	MS	Terminated
DSH250001AJ	Child	DSH	University of Mississippi Medical Center	Pavilion Medicine Clinic Suite G - Pavilion Medicine Clinic Suite G	2500 North State Street	Jackson	MS	Active
DSH250001AK	Child	DSH	University of Mississippi Medical Center	STATE OF MISSISSIPPI - UNIVERSITY - CH Peds Urgent Care	1010 LAKELAND PL	FLOWOOD	MS	Active
DSH250001B	Child	DSH	University of Mississippi Medical Center	CANCER INSTITUTE	350 WEST WOODROW WILSON	JACKSON	MS	Active
DSH250001E	Child	DSH	UNIVERSITY HOSPITALS AND CLINICS	Communicative Sciences (JMM Audiology)	350 West Woodrow Wilson Avenue	Jackson	MS	Terminated
DSH250001F	Child	DSH	University of Mississippi Medical Center	SS Cardiac-Rehab Univ Heart	5903 Ridgewood Road	Jackson	MS	Active
DSH250001G	Child	DSH	University of Mississippi Medical Center	SS Select Heart Clinic	5903 Ridgewood Road	Jackson	MS	Active
DSH250001H	Child	DSH	University of Mississippi Medical Center	Center for Advancement of Youth	4400 Old Canton Road	Jackson	MS	Active
DSH250001J	Child	DSH	University of Mississippi Medical Center	SS Sleep Disorder Center	5903 Ridgewood Road	Jackson	MS	Active
DSH250001K	Child	DSH	University of Mississippi Medical Center	Dialysis-Home	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001L	Child	DSH	University of Mississippi Medical Center	JMM Dialysis--Outpatient Mall	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001M	Child	DSH	University of Mississippi Medical Center	Batson Kid's Clinic	421 South Stadium Drive	Jackson	MS	Active
DSH250001N	Child	DSH	University of Mississippi Medical Center	Batson Specialty Clinic	421 South Stadium Drive	Jackson	MS	Terminated
DSH250001P	Child	DSH	University of Mississippi Medical Center	JMM Pain Management Clinic-Mall	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001Q	Child	DSH	University of Mississippi Medical Center	JMM Peds Allergy (Pediatric Allergy Clinic-Mall)	350 West Woodrow Wilson Avenue	Jackson	MS	Terminated
DSH250001R	Child	DSH	University of Mississippi Medical Center	JMM Surgical Specialty Clinic-Mall	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001S	Child	DSH	University of Mississippi Medical Center	JMM Medicine Specialty Clinic-Mall	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001T	Child	DSH	University of Mississippi Medical Center	JMM Bleeding Disorder Clinic (Hemostasis & Thrombosis Center)	350 West Woodrow Wilson	Jackson	MS	Terminated
DSH250001U	Child	DSH	University of Mississippi Medical Center	JMM Renal Clinic-Mall	350 West Woodrow Wilson	Jackson	MS	Active
DSH250001V	Child	DSH	University of Mississippi Medical Center	JMM-Anticoag (Pharmacy Care Clinic-Mall)	350 West Woodrow Wilson	Jackson	MS	Active
DSH250001W	Child	DSH	University of Mississippi Medical Center	JMM-Psychiatry Clinic (Mall)	350 West Woodrow Wilson	Jackson	MS	Terminated
DSH250001X	Child	DSH	University of Mississippi Medical Center	JMM OB/GYN Clinic-Mall	350 West Woodrow Wilson Avenue	Jackson	MS	Active
DSH250001Y	Child	DSH	University of Mississippi Medical Center	Infusion Center-Select	5903 Ridgewood Road	Jackson	MS	Active
DSH250001Z	Child	DSH	University of Mississippi Medical Center	Wound Care Center	2500 North State Street	Jackson	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Recertification	1410 East Woodrow Wilson Avenue Suite H Jackson, MS 39216	2500 North State Street Suite H Jackson, MS 39216	9/6/2024 9:53 AM
Details	Last Recertification Date	Update	Recertification	9/5/2023 2:54:49 PM	9/6/2024 9:53:53 AM	9/6/2024 9:53 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 11:18:02 AM	9/5/2023 2:54:49 PM	9/5/2023 2:54 PM
Details	Entity Subname	Update	Recertification	Pavilion Transplant Clinic - Transplant	Pavilion Transplant Clinic	9/5/2023 2:54 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00020149 (MS)		9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00020256 (MS)		9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	09903368 (MS)		9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00330385 (MS)		9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	06300271 (MS)		9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000020149	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000020256	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000330385	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		006300271	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		009903368	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	9/9/2022 3:32 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	20149 (MS)		9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00020149	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00020256	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		09903368	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00330385	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		06300271	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HOS1149N	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AL	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		372079	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		XHDP42759	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		23487232	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		022089500	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000108776B	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		646008520001	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200125970A	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01430321	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1731200	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01691529	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		188845	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100698520A	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500691621	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10473A	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0250001	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		072271201	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194930693	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477734689	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/6/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/6/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/6/2022 11:18 AM
Details	Last Recertification Date	Update	Recertification	9/14/2021 2:12:52 PM	9/6/2022 11:18:02 AM	9/6/2022 11:18 AM
Contacts	Primary Contact	Update	Change Request	Mayhood, William E Supervisor-340b Compliance University of Mississippi Medical Center 6019842676	Raymer, Kelsey H Health System 340B Operations Director University of Mississippi Medical Center 6019842676	6/1/2022 2:16 PM
Addresses	Main Address	Update	Recertification	1410 E. Woodrow Wilson Jackson, MS 39216	1410 East Woodrow Wilson Avenue Suite H Jackson, MS 39216	9/14/2021 2:12 PM
Addresses	Shipping Address	Insert	Recertification		University of Mississippi Medical Center 2500 North State Street Jackson, MS 39216	9/14/2021 2:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649419532	9/14/2021 2:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/14/2021 2:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1932144342	9/14/2021 2:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/14/2021 2:12 PM
Details	Last Recertification Date	Update	Recertification	9/14/2020 3:26:41 PM	9/14/2021 2:12:52 PM	9/14/2021 2:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1154317527	9/14/2020 3:26 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/14/2020 3:26 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1154317527 ( )		9/14/2020 3:26 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 6:33:57 PM	9/14/2020 3:26:41 PM	9/14/2020 3:26 PM
Contacts	Primary Contact	Update	Change Request	Ratliff, Ryan Dir-340b Operations University of Mississippi Medical Center 6019842676	Mayhood, William E Supervisor-340b Compliance University of Mississippi Medical Center 6019842676	5/12/2020 10:26 AM
Contacts	Authorizing Official	Update	Profile Change Request	Grimsley, Jeffrey Assistant CFO University of MIssissippi Medical Center 6018158732	Grimsley, Jeffrey CFO-Health System University of MIssissippi Medical Center 6018156270	5/4/2020 10:09 AM
Contacts	Signed By	Update	Profile Change Request	Grimsley, Jeffrey Assistant CFO University of MIssissippi Medical Center 6018158732	Grimsley, Jeffrey CFO-Health System University of MIssissippi Medical Center 6018156270	5/4/2020 10:09 AM
Contacts	Primary Contact	Update	Change Request	Baughn, Stacy Director Business Operations, Pharmacy University of Mississippi Medical Center 6018151791	Ratliff, Ryan Dir-340b Operations University of Mississippi Medical Center 6019842676	2/24/2020 1:16 PM
Details	Last Recertification Date	Update	Recertification		8/20/2019 6:33:57 PM	8/20/2019 6:33 PM
Contacts	Primary Contact	Update	Change Request	Mayhood, William E Supervisor-340b Compliance University of Mississippi Medical Center 6019842676	Baughn, Stacy Director Business Operations, Pharmacy University of Mississippi Medical Center 6018151791	7/23/2019 7:11 AM
Contacts	Primary Contact	Update	Change Request	Baughn, Stacy Director Business Operations, Pharmacy University of Mississippi Medical Center 6018151791	Mayhood, William E Supervisor-340b Compliance University of Mississippi Medical Center 6019842676	4/26/2019 12:50 PM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Addresses	Main Address	Insert	New Registration		1410 E. Woodrow Wilson Jackson, MS 39216	1/31/2019 2:39 PM
Addresses	Billing Address	Insert	New Registration		University of Mississippi Medical Center Attn: Pharmacy 2500 North State Street Jackson, MS 39216	1/31/2019 2:39 PM
Contacts	Signed By	Insert	New Registration		Grimsley, Jeffrey Assistant CFO University of MIssissippi Medical Center 6018158732	1/31/2019 2:39 PM
Details	340B ID	Update	New Registration		DSH250001AG	1/31/2019 2:39 PM
Details	Entity Name	Update	New Registration	UNIVERSITY OF MISSISSIPPI MEDICAL	University of Mississippi Medical Center	1/31/2019 2:39 PM
Details	Entity Subname	Update	New Registration	Pavilion Transplant Clinic	Pavilion Transplant Clinic - Transplant	1/31/2019 2:39 PM
Dates	Participating Approval Date	Update	New Registration		1/31/2019 2:39:08 PM	1/31/2019 2:39 PM
Details	State	Update	New Registration	Pending	Approved	1/31/2019 2:39 PM
Dates	Signed By Date	Update	New Registration		1/31/2019 1:07:45 PM	1/31/2019 2:39 PM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	1/31/2019 2:39 PM
Addresses	Main Address	Insert	New Registration		1410 E. Woodrow Wilson Jackson, MS 39216	1/14/2019 5:01 PM
Addresses	Billing Address	Insert	New Registration		University of Mississippi Medical Center Attn: Pharmacy 2500 North State Street Jackson, MS 39216	1/14/2019 5:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/14/2019 5:01 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		20149	1/14/2019 5:01 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	1/14/2019 5:01 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1154317527	1/14/2019 5:01 PM
Contacts	Authorizing Official	Insert	New Registration		Grimsley, Jeffrey Assistant CFO University of MIssissippi Medical Center 6018158732	1/14/2019 5:01 PM
Contacts	Primary Contact	Insert	New Registration		Baughn, Stacy Director Business Operations, Pharmacy University of Mississippi Medical Center 6018151791	1/14/2019 5:01 PM
Details	Last Recertification Date	Insert	New Registration			1/14/2019 5:01 PM
Details	Grant Number	Insert	New Registration			1/14/2019 5:01 PM
Details	340B ID	Insert	New Registration			1/14/2019 5:01 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/14/2019 5:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/14/2019 5:01 PM
Details	Medicare Provider Number	Insert	New Registration		250001	1/14/2019 5:01 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY OF MISSISSIPPI MEDICAL	1/14/2019 5:01 PM
Details	Program Code	Insert	New Registration		DSH	1/14/2019 5:01 PM
Details	Entity Subname	Insert	New Registration		Pavilion Transplant Clinic	1/14/2019 5:01 PM
Dates	Participating Approval Date	Insert	New Registration			1/14/2019 5:01 PM
Details	State	Insert	New Registration		Pending	1/14/2019 5:01 PM
Dates	Registration Date	Insert	New Registration		1/14/2019 5:01:53 PM	1/14/2019 5:01 PM
Dates	Signed By Date	Insert	New Registration			1/14/2019 5:01 PM
Dates	Start Date	Insert	New Registration			1/14/2019 5:01 PM
Terminations	Termination Comments	Insert	New Registration			1/14/2019 5:01 PM
Terminations	Termination Date	Insert	New Registration			1/14/2019 5:01 PM
Terminations	Termination Effective Date	Insert	New Registration			1/14/2019 5:01 PM
Terminations	Termination Reason	Insert	New Registration			1/14/2019 5:01 PM