Covered Entity Details

DSH040071R JEFFERSON REGIONAL MEDICAL CENTER (Active) - information as of 5/7/2025 10:43:24 PM

Main Details

Name

JEFFERSON REGIONAL MEDICAL CENTER

Subdivision Name

Ambulatory Surgery Center - Outpatient Surgery

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH040071R

Medicare Provider Number

040071

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/8/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/22/2019

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Jefferson Hospital Association, Inc.
Jeremy Jeffery, Senior Vice President & Chief Financial Officer
(870) 541-5945

Primary Contact

Jeffeson Regional Medical Center
Kenneth Alan Hawk, 340B Program Director
(870) 541-3340

Addresses

Street Address

1609 West 40th Ave
Pine Bluff, AR 71603

Billing Address

Jefferson Regional Medical Center
1600 West 40th Avenue
Pine Bluff, AR 71603

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
AR	100339407	1710931985

Shipping Addresses

Shipping Address 1

Jefferson Regional Medical Center
1600 West 40th Avenue
Pine Bluff, AR 71603

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
DSH040071B	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	WHITE HALL HEALTH COMPLEX PHYSICAL THERAPY CLINIC	1600 WEST HOLLAND AVENUE	WHITE HALL	AR	Terminated
DSH040071C	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Center on Aging	4747 Dusty Lake Drive #101	Pine Bluff	AR	Terminated
DSH040071D	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	ENDOCRINOLOGY OF SOUTH ARKANSAS	7500 DOLLARWAY RD	WHITE HALL	AR	Active
DSH040071E	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	SOUTH ARKANSAS ORTHOPAEDIC CENTER	1609 W 40TH AVENUE	PINE BLUFF	AR	Active
DSH040071F	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Healthworks / MTM	4201 South Mulberry	PINE BLUFF	AR	Active
DSH040071G	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	CARDIOLOGY ASSOCIATES	1609 W 40TH AVE	PINE BLUFF	AR	Active
DSH040071H	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	South Arkansas Cardiovascular Surgery Center	1609 W 40th Ave	Pine Bluff	AR	Terminated
DSH040071J	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Surgical Associates of SE Arkansas	1601 W 40th Ave	Pine Bluff	AR	Active
DSH040071K	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Pine Bluff Specialty Clinic	1609 W 40th Ave	Pine Bluff	AR	Active
DSH040071L	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Neurosurgery Associates of South Arkansas	1609 W 40th Ave	Pine Bluff	AR	Terminated
DSH040071M	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	JRMC Urgent Care Center	4201 S Mulberry Street	Pine Bluff	AR	Active
DSH040071N	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Family Health Associates of South Arkansas	4747 Dusty Lake Drive	Pine Bluff	AR	Active
DSH040071P	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	JRMC Physician Network - GI Clinic	1801 West 40th	Pine Bluff	AR	Active
DSH040071Q	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Outpatient Services - Infusion Center	1609 W 40th Avenue	Pine Bluff	AR	Active
DSH040071R	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Ambulatory Surgery Center - Outpatient Surgery	1609 West 40th Ave	Pine Bluff	AR	Active
DSH040071S	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Pain Specialist of South Arkansas - Pain Clinic	1609 West 40th Suite 203	Pine Bluff	AR	Terminated
DSH040071T	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Jefferson Regional Cancer Center - Oncology	1609 W 40th	Pine Bluff	AR	Active
DSH040071U	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	Otolaryngology - Otolaryngology	1801 West 40th Avenue	Pine Bluff	AR	Active
DSH040071V	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	JEFFERSON HOSPITAL ASSOCIATION INC - Wound Care Clinic	4310 S MULBERRY STREET	PINE BLUFF	AR	Active
DSH040071W	Child	DSH	JEFFERSON REGIONAL MEDICAL CENTER	JEFFERSON HOSPITAL ASSOCIATION INC. - Rheumatology Associates	1420 W 43RD AVE	PINE BLUFF	AR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Recertification	1409 w 40TH Ave Pine Bluff, AR 71603	1609 West 40th Ave Pine Bluff, AR 71603	9/6/2024 4:03 PM
Addresses	Billing Address	Insert	Recertification		Jefferson Regional Medical Center 1600 West 40th Avenue Pine Bluff, AR 71603	9/6/2024 4:03 PM
Addresses	Shipping Address	Insert	Recertification		Jefferson Regional Medical Center 1600 West 40th Avenue Pine Bluff, AR 71603	9/6/2024 4:03 PM
Details	Last Recertification Date	Update	Recertification	8/28/2023 2:45:48 PM	9/6/2024 4:03:36 PM	9/6/2024 4:03 PM
Contacts	Authorizing Official	Update	AO Change Request	JACKSON, BRYAN CHIEF ADMINISTRATIVE OFFICER Jefferson Regional Medical Center 8705417141	Jeffery, Jeremy Senior Vice President & Chief Financial Officer Jefferson Hospital Association, Inc. 8705415945	3/26/2024 7:02 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 3:59:31 PM	8/28/2023 2:45:48 PM	8/28/2023 2:45 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 2:17:33 PM	9/6/2022 3:59:31 PM	9/6/2022 3:59 PM
Details	Last Recertification Date	Update	Recertification	9/13/2020 9:20:53 PM	9/10/2021 2:17:33 PM	9/10/2021 2:17 PM
Contacts	Primary Contact	Update	Change Request	Stice, Lelan Director of Pharmacy Jefferson Regional Medical Center 8705417908	Hawk, Kenneth Alan 340B Program Director Jeffeson Regional Medical Center 8705413340	12/21/2020 7:34 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1710931985 ( )		9/13/2020 9:20 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1710931985	9/13/2020 9:20 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/13/2020 9:20 PM
Details	Last Recertification Date	Update	Recertification		9/13/2020 9:20:53 PM	9/13/2020 9:20 PM
Contacts	Authorizing Official	Update	Profile Change Request	JACKSON, BRYAN CHIEF FINANCIAL OFFICER Jefferson Regional Medical Center 8705417141	JACKSON, BRYAN CHIEF ADMINISTRATIVE OFFICER Jefferson Regional Medical Center 8705417141	8/17/2020 10:02 AM
Contacts	Signed By	Update	Profile Change Request	JACKSON, BRYAN CHIEF FINANCIAL OFFICER Jefferson Regional Medical Center 8705417141	JACKSON, BRYAN CHIEF ADMINISTRATIVE OFFICER Jefferson Regional Medical Center 8705417141	8/17/2020 10:02 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		JACKSON, BRYAN CHIEF FINANCIAL OFFICER Jefferson Regional Medical Center 8705417141	10/22/2019 10:19 AM
Details	340B ID	Update	New Registration		DSH040071R	10/22/2019 10:19 AM
Details	Entity Subname	Update	New Registration	Ambulatory Surgery Center	Ambulatory Surgery Center - Outpatient Surgery	10/22/2019 10:19 AM
Dates	Participating Approval Date	Update	New Registration		10/22/2019 10:19:26 AM	10/22/2019 10:19 AM
Details	State	Update	New Registration	Pending	Approved	10/22/2019 10:19 AM
Dates	Signed By Date	Update	New Registration		10/15/2019 10:49:08 AM	10/22/2019 10:19 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/22/2019 10:19 AM
Addresses	Main Address	Insert	New Registration		1409 w 40TH Ave Pine Bluff, AR 71603	10/8/2019 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/8/2019 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100339407	10/8/2019 1:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	10/8/2019 1:54 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710931985	10/8/2019 1:54 PM
Contacts	Authorizing Official	Insert	New Registration		JACKSON, BRYAN CHIEF FINANCIAL OFFICER Jefferson Regional Medical Center 8705417141	10/8/2019 1:54 PM
Contacts	Primary Contact	Insert	New Registration		Stice, Lelan Director of Pharmacy Jefferson Regional Medical Center 8705417908	10/8/2019 1:54 PM
Details	Last Recertification Date	Insert	New Registration			10/8/2019 1:54 PM
Details	Grant Number	Insert	New Registration			10/8/2019 1:54 PM
Details	340B ID	Insert	New Registration			10/8/2019 1:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/8/2019 1:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/8/2019 1:54 PM
Details	Medicare Provider Number	Insert	New Registration		040071	10/8/2019 1:54 PM
Details	Entity Name	Insert	New Registration		JEFFERSON REGIONAL MEDICAL CENTER	10/8/2019 1:54 PM
Details	Program Code	Insert	New Registration		DSH	10/8/2019 1:54 PM
Details	Entity Subname	Insert	New Registration		Ambulatory Surgery Center	10/8/2019 1:54 PM
Dates	Participating Approval Date	Insert	New Registration			10/8/2019 1:54 PM
Details	State	Insert	New Registration		Pending	10/8/2019 1:54 PM
Dates	Registration Date	Insert	New Registration		10/8/2019 1:54:32 PM	10/8/2019 1:54 PM
Dates	Signed By Date	Insert	New Registration			10/8/2019 1:54 PM
Dates	Start Date	Insert	New Registration			10/8/2019 1:54 PM
Terminations	Termination Comments	Insert	New Registration			10/8/2019 1:54 PM
Terminations	Termination Date	Insert	New Registration			10/8/2019 1:54 PM
Terminations	Termination Effective Date	Insert	New Registration			10/8/2019 1:54 PM
Terminations	Termination Reason	Insert	New Registration			10/8/2019 1:54 PM