Covered Entity Details

DSH260070K PEMISCOT COUNTY MEMORIAL HOSPITAL (Active) - information as of 6/27/2025 6:03:50 AM

Main Details

Name

PEMISCOT COUNTY MEMORIAL HOSPITAL

Subdivision Name

Pain Management - Injection Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260070K

Medicare Provider Number

260070

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2020

Participating Start Date

7/1/2020

Participating Approval Date

5/21/2020

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Pemiscot County Memorial Hospital
Kacy Howell, Pharmacist
(573) 359-6147

Primary Contact

PEMISCOT MEMORIAL HEALTH SYSTEMS
Loren Clifton, Pharmacy Technican
(573) 359-3612

Addresses

Street Address

225 North Hwy J
Hayti, MO 63851

Billing Address

Pemiscot Memorial Health Systems
PO BOX 489
Hayti, MO 63851

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
MO	010988509	1437179710

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
DSH260070A	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Pemiscot Primary Care (Hayti Clinic)	907 East Reed	Hayti	MO	Active
DSH260070B	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Doctors Clinic	106 W 12TH ST	CARUTHERSVILLE	MO	Active
DSH260070C	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Portageville Primary Care	314 East Main	Portageville	MO	Terminated
DSH260070D	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Pemiscot Primary Care Clinic - Kennett	1231 First Street	Kennett	MO	Active
DSH260070E	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	PMHS Convenient Care	946 East Reed	Hayti	MO	Active
DSH260070F	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	BOOTHEEL PRIMARY CARE CLINIC-STEELE	213 SOUTH WALNUT STREET	STEELE	MO	Active
DSH260070G	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Bootheel Primary Care - New Madrid	555 Virginia Avenue	New Madrid	MO	Terminated
DSH260070H	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Bootheel Primary Care - Caruthersville	1502 Ward Avenue	Caruthersville	MO	Active
DSH260070J	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Physicians Diagnostic Center - Advanced Diagnostic Center	225 North Hwy J	Hayti	MO	Active
DSH260070K	Child	DSH	PEMISCOT COUNTY MEMORIAL HOSPITAL	Pain Management - Injection Clinic	225 North Hwy J	Hayti	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	KETCHUM, DAVID CEO Pemiscot Memorial Health Systems 5733593579	Howell, Kacy Pharmacist Pemiscot County Memorial Hospital 5733596147	6/3/2025 6:12 AM
Details	Last Recertification Date	Update	Recertification	8/17/2023 10:25:47 AM	8/14/2024 5:02:50 PM	8/14/2024 5:02 PM
Contacts	Primary Contact	Update	Group Change Request	Cooper, Rosie 340B Pharmacy Technician Pemiscot Memorial Health Systems 5732596174	Clifton, Loren Pharmacy Technican PEMISCOT MEMORIAL HEALTH SYSTEMS 5733593612	4/1/2024 8:44 AM
Contacts	Authorizing Official	Update	Profile Change Request	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	KETCHUM, DAVID CEO Pemiscot Memorial Health Systems 5733593579	4/1/2024 8:43 AM
Contacts	Primary Contact	Update	Group Change Request	Carpenter, Tammy 340B CPhT Pemiscot County Memorial Hospital 5733593454	Cooper, Rosie 340B Pharmacy Technician Pemiscot Memorial Health Systems 5732596174	11/27/2023 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 9:41:28 AM	8/17/2023 10:25:47 AM	8/17/2023 10:25 AM
Contacts	Authorizing Official	Update	Change Request	Ward, Leigha Kristen Chief Financial Officer Pemiscot County Memorial Hospital 5733593612	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	1/9/2023 7:46 AM
Contacts	Primary Contact	Update	Group Change Request	KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	Carpenter, Tammy 340B CPhT Pemiscot County Memorial Hospital 5733593454	1/4/2023 12:09 PM
Addresses	Main Address	Update	Recertification	907 East Reed - West Hayti, MO 63851	225 North Hwy J Hayti, MO 63851	8/25/2022 9:41 AM
Addresses	Shipping Address	Delete	Recertification	Pemiscot Memorial Hospital 946 E Reed St Hayti, MO 63851		8/25/2022 9:41 AM
Details	Last Recertification Date	Update	Recertification	8/30/2021 9:52:19 AM	8/25/2022 9:41:28 AM	8/25/2022 9:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010988509	9/13/2021 1:27 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	9/13/2021 1:27 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437179710	9/13/2021 1:27 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	9/13/2021 1:27 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 9:20:04 AM	8/30/2021 9:52:19 AM	8/30/2021 9:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010988509 (MO)		6/14/2021 4:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1437179710 (MO)		6/14/2021 4:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/18/2020 9:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		010988509	8/18/2020 9:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	8/18/2020 9:20 AM
Medicaid Billing	NPI: State	Update	Recertification		MO	8/18/2020 9:20 AM
Details	Last Recertification Date	Update	Recertification		8/18/2020 9:20:04 AM	8/18/2020 9:20 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Ward, Leigha Kristen Chief Financial Officer Pemiscot County Memorial Hospital 5733593612	5/21/2020 1:30 PM
Details	340B ID	Update	New Registration		DSH260070K	5/21/2020 1:30 PM
Details	Entity Subname	Update	New Registration	Pain Management	Pain Management - Injection Clinic	5/21/2020 1:30 PM
Dates	Participating Approval Date	Update	New Registration		5/21/2020 1:30:28 PM	5/21/2020 1:30 PM
Details	State	Update	New Registration	Pending	Approved	5/21/2020 1:30 PM
Dates	Signed By Date	Update	New Registration		5/19/2020 3:07:01 PM	5/21/2020 1:30 PM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	5/21/2020 1:30 PM
Addresses	Main Address	Insert	New Registration		907 East Reed - West Hayti, MO 63851	4/15/2020 9:45 AM
Addresses	Billing Address	Insert	New Registration		Pemiscot Memorial Health Systems PO BOX 489 Hayti, MO 63851	4/15/2020 9:45 AM
Addresses	Shipping Address	Insert	New Registration		Pemiscot Memorial Hospital 946 E Reed St Hayti, MO 63851	4/15/2020 9:45 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1437179710	4/15/2020 9:45 AM
Contacts	Authorizing Official	Insert	New Registration		Ward, Leigha Kristen Chief Financial Officer Pemiscot County Memorial Hospital 5733593612	4/15/2020 9:45 AM
Contacts	Primary Contact	Insert	New Registration		KETCHUM, DAVID DIRECTOR OF PHARMACY Pemiscot Memorial Health Systems 5733593579	4/15/2020 9:45 AM
Details	Last Recertification Date	Insert	New Registration			4/15/2020 9:45 AM
Details	Grant Number	Insert	New Registration			4/15/2020 9:45 AM
Details	340B ID	Insert	New Registration			4/15/2020 9:45 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2020 9:45 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2020 9:45 AM
Details	Medicare Provider Number	Insert	New Registration		260070	4/15/2020 9:45 AM
Details	Entity Name	Insert	New Registration		PEMISCOT COUNTY MEMORIAL HOSPITAL	4/15/2020 9:45 AM
Details	Program Code	Insert	New Registration		DSH	4/15/2020 9:45 AM
Details	Entity Subname	Insert	New Registration		Pain Management	4/15/2020 9:45 AM
Dates	Participating Approval Date	Insert	New Registration			4/15/2020 9:45 AM
Details	State	Insert	New Registration		Pending	4/15/2020 9:45 AM
Dates	Registration Date	Insert	New Registration		4/15/2020 9:45:43 AM	4/15/2020 9:45 AM
Dates	Signed By Date	Insert	New Registration			4/15/2020 9:45 AM
Dates	Start Date	Insert	New Registration			4/15/2020 9:45 AM
Terminations	Termination Comments	Insert	New Registration			4/15/2020 9:45 AM
Terminations	Termination Date	Insert	New Registration			4/15/2020 9:45 AM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2020 9:45 AM
Terminations	Termination Reason	Insert	New Registration			4/15/2020 9:45 AM