Covered Entity Details

CAH251300-12 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL (Terminated) - information as of 5/6/2025 12:04:04 AM

Main Details

Name

INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

Subdivision Name

INDEPENDENT HEALTHCARE MANAGEMENT I - Forest Family Medical Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH251300-12

Medicare Provider Number

251300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/4/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/17/2019

Last Recertification Date

9/19/2022

Termination Date
Termination Reason

10/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Lackey Memorial Hospital
sydney sawyer, ceo
(601) 469-4151 Ext: 301

Primary Contact

Lackey Memorial Hospital - Magee, MS
Carol Denton, Integrity Officer/Privacy & Security
(601) 209-3483

Addresses

Street Address

1 MEDICAL LN STE B
FOREST FAMILY PRACTICE
FOREST, MS 39074-4039

Billing Address

Independent Healthcare Management, Inc.
P O Box 1460
Magee, MS 39111

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

Same as Street Address

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
CAH251300-01	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Main Street Medical Clinic of Sebastopol	17509 Highway 21	Sebastapol	MS	Terminated
CAH251300-02	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Main Street Medical Clinic of Morton	347 South 4th Street	Morton	MS	Active
CAH251300-03	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Community Health Clinic	505 Airport Road	Forest	MS	Active
CAH251300-04	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Lackey Outpatient Behavioral Health of Forest	1084-A Highway 35 South	Forest	MS	Active
CAH251300-05	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Lackey Outpatient Behavioral Health of Carthage	105 Van Buren Street	Carthage	MS	Active
CAH251300-06	Child	CAH	SE LACKEY CAH AND NURSING HOME	Lackey Outpatient Behavioral Health of Pelahatchie	505 2nd Street	Pelathatchie	MS	Terminated
CAH251300-07	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Lackey Outpatient Behavioral Health of Philadelphia	220 Hospital Road	Philadelphia	MS	Active
CAH251300-08	Child	CAH	SE LACKEY CAH AND NURSING HOME	MAIN STREET MEDICAL CLINIC OF SEBAS	17509 HWY 21	SEBASTOPOL	MS	Terminated
CAH251300-09	Child	CAH	SE LACKEY CAH AND NURSING HOME	MAIN STREET MEDICAL CLINIC OF MORTON	347 SOUTH 4TH STREET	MORTON	MS	Terminated
CAH251300-10	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	LACKEY PEDIATRIC CLINIC	1 Medical Lane	FOREST	MS	Active
CAH251300-11	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT I - Newton Family and Pediatric Clinic	NEWTON FAMILY AND PEDIATRIC CLINIC	NEWTON	MS	Active
CAH251300-12	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT I - Forest Family Medical Clinic	1 MEDICAL LN STE B	FOREST	MS	Terminated
CAH251300-13	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT, INC - 149 Pediatric and Family	376 Simpson Hwy 149, Suite 600	Magee	MS	Active
CAH251300-14	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	Specialty Clinic - Multispecialty clinic services	505 Airport Road	Forest	MS	Active
CAH251300-15	Child	CAH	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGEMENT I - 35 South Family Medical	342 MAGNOLIA DR	RALEIGH	MS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/17/2023 12:00:00 AM	7/26/2023 6:44 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/26/2023 6:44 AM
Terminations	Termination Comments	Update	Termination Request		Clinic consolidation as of 7/17/23 not due to ineligibility.	7/26/2023 6:44 AM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	7/26/2023 6:44 AM
Terminations	Termination Effective Date	Update	Termination Request		7/17/2023 12:00:00 AM	7/26/2023 6:44 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	7/26/2023 6:44 AM
Addresses	Billing Address	Update	Change Request	Kanopy Healthcare Partners P O Box 1460 Magee, MS 39111	Independent Healthcare Management, Inc. P O Box 1460 Magee, MS 39111	7/6/2023 2:57 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 3:11:44 PM	9/19/2022 2:51:41 PM	9/19/2022 2:51 PM
Addresses	Billing Address	Insert	Change Request		Kanopy Healthcare Partners P O Box 1460 Magee, MS 39111	2/22/2022 10:54 AM
Details	Last Recertification Date	Update	Recertification	8/18/2020 10:50:28 AM	8/24/2021 3:11:44 PM	8/24/2021 3:11 PM
Contacts	Primary Contact	Update	Group Change Request	Lott, Trent Pharmacist Lackey Memorial Hospital 6014694151-391	Denton, Carol Integrity Officer/Privacy & Security Lackey Memorial Hospital - Magee, MS 6012093483	7/12/2021 9:15 AM
Details	Last Recertification Date	Update	Recertification		8/18/2020 10:50:28 AM	8/18/2020 10:50 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Authorizing Official	Update	Change Request	Sawyer, Sydney CEO Lackey Memorial Hopsital 6014694151-301	sawyer, sydney ceo Lackey Memorial Hospital 6014694151-301	12/30/2019 7:55 AM
Contacts	Signed By	Insert	New Registration		Sawyer, Sydney CEO Lackey Memorial Hopsital 6014694151-301	10/17/2019 2:43 PM
Details	340B ID	Update	New Registration		CAH251300-12	10/17/2019 2:43 PM
Details	Entity Name	Update	New Registration	LACKEY MEMORIAL HOSPITAL	INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL	10/17/2019 2:43 PM
Details	Entity Subname	Update	New Registration	INDEPENDENT HEALTHCARE MANAGEMENT I	INDEPENDENT HEALTHCARE MANAGEMENT I - Forest Family Medical Clinic	10/17/2019 2:43 PM
Dates	Participating Approval Date	Update	New Registration		10/17/2019 2:43:07 PM	10/17/2019 2:43 PM
Details	State	Update	New Registration	Pending	Approved	10/17/2019 2:43 PM
Dates	Signed By Date	Update	New Registration		10/17/2019 11:20:39 AM	10/17/2019 2:43 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/17/2019 2:43 PM
Addresses	Main Address	Insert	New Registration		1 MEDICAL LN STE B FOREST FAMILY PRACTICE FOREST, MS 39074-4039	10/4/2019 2:45 PM
Contacts	Authorizing Official	Insert	New Registration		Sawyer, Sydney CEO Lackey Memorial Hopsital 6014694151-301	10/4/2019 2:45 PM
Contacts	Primary Contact	Insert	New Registration		Lott, Trent Pharmacist Lackey Memorial Hospital 6014694151-391	10/4/2019 2:45 PM
Details	Last Recertification Date	Insert	New Registration			10/4/2019 2:45 PM
Details	Grant Number	Insert	New Registration			10/4/2019 2:45 PM
Details	340B ID	Insert	New Registration			10/4/2019 2:45 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/4/2019 2:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/4/2019 2:45 PM
Details	Medicare Provider Number	Insert	New Registration		251300	10/4/2019 2:45 PM
Details	Entity Name	Insert	New Registration		LACKEY MEMORIAL HOSPITAL	10/4/2019 2:45 PM
Details	Program Code	Insert	New Registration		CAH	10/4/2019 2:45 PM
Details	Entity Subname	Insert	New Registration		INDEPENDENT HEALTHCARE MANAGEMENT I	10/4/2019 2:45 PM
Dates	Participating Approval Date	Insert	New Registration			10/4/2019 2:45 PM
Details	State	Insert	New Registration		Pending	10/4/2019 2:45 PM
Dates	Registration Date	Insert	New Registration		10/4/2019 2:45:01 PM	10/4/2019 2:45 PM
Dates	Signed By Date	Insert	New Registration			10/4/2019 2:45 PM
Dates	Start Date	Insert	New Registration			10/4/2019 2:45 PM
Terminations	Termination Comments	Insert	New Registration			10/4/2019 2:45 PM
Terminations	Termination Date	Insert	New Registration			10/4/2019 2:45 PM
Terminations	Termination Effective Date	Insert	New Registration			10/4/2019 2:45 PM
Terminations	Termination Reason	Insert	New Registration			10/4/2019 2:45 PM