Covered Entity Details

RRC040039-01 Arkansas Methodist Medical Center (Terminated) - information as of 4/30/2025 10:52:39 PM

Main Details

Name

Arkansas Methodist Medical Center

Subdivision Name

ARKANSAS METHODIST HOSPITAL CORP - Family Practice

Type

Rural Referral Center

Rural

Yes

340B ID

RRC040039-01

Medicare Provider Number

040039

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/13/2021

Participating Start Date

4/1/2021

Participating Approval Date

3/5/2021

Last Recertification Date

8/15/2023

Termination Date
Termination Reason

1/1/2024
Change of covered entity type

Contacts

Authorizing Official

Arkansas Methodist Medical Center
Staci J Williams, CFO
(870) 239-7105

Primary Contact

Arkansas Methodist Medical Center
Stan Carmack, Pharm.D.
(870) 239-7861

Addresses

Street Address

1110 W KINGSHIGHWAY
AMMC Family Practice
PARAGOULD, AR 72450-4197

Billing Address

AMMC Physician Group
1000 W Kingshighway, Ste 14
Paragould, AR 72450-4197

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
RRC040039-01	Child	RRC	Arkansas Methodist Medical Center	ARKANSAS METHODIST HOSPITAL CORP - Family Practice	1110 W KINGSHIGHWAY	PARAGOULD	AR	Terminated
RRC040039-02	Child	RRC	Arkansas Methodist Medical Center	AMMC ENT - Ear, Nose, and Throat	1000 W Kingshighway, Suite 3	Paragould	AR	Terminated
RRC040039-03	Child	RRC	Arkansas Methodist Medical Center	AMMC Women's Clinic - OB/Gynecology	1110 W KINGSHIGHWAY	Paragould	AR	Terminated
RRC040039-04	Child	RRC	Arkansas Methodist Medical Center	AMMC Hines Family Medicine - Family Practice	1300 W Court St	Paragould	AR	Terminated
RRC040039-05	Child	RRC	Arkansas Methodist Medical Center	AMMC Surgery Clinic - Surgery	1000 W Kingshighway, Suite 13	Paragould	AR	Terminated
RRC040039-06	Child	RRC	Arkansas Methodist Medical Center	Urology Specialists of Paragould - Urology	4000 Linwood Drive	Paragould	AR	Terminated
RRC040039-07	Child	RRC	Arkansas Methodist Medical Center	Paragould Plastic Surgery - Plastic Surgery	1000 W Kingshighway, Suite 7	Paragould	AR	Terminated
RRC040039-08	Child	RRC	Arkansas Methodist Medical Center	AMMC Orthopaedic Associates - Orthopedic	4000 Linwood Drive, Suite I	Paragould	AR	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Williams, Staci J Controller Arkansas Methodist Medical Center 8702397855	Williams, Staci J CFO Arkansas Methodist Medical Center 8702397105	12/9/2024 10:47 AM
Contacts	Signed By	Update	Profile Change Request	Williams, Staci J Controller Arkansas Methodist Medical Center 8702397855	Williams, Staci J CFO Arkansas Methodist Medical Center 8702397105	12/9/2024 10:47 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	10/24/2023 12:12 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	10/24/2023 12:12 PM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	10/24/2023 12:12 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2024 12:00:00 AM	10/24/2023 12:12 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	10/24/2023 12:12 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 9:03:29 AM	8/15/2023 12:58:48 PM	8/15/2023 12:58 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 3:56:24 PM	8/26/2022 9:03:29 AM	8/26/2022 9:03 AM
Details	Last Recertification Date	Update	Recertification		8/30/2021 3:56:24 PM	8/30/2021 3:56 PM
Contacts	Authorizing Official	Update	Profile Change Request	Williams, Staci J Controller/Interim CFO Arkansas Methodist Medical Center 8702397855	Williams, Staci J Controller Arkansas Methodist Medical Center 8702397855	4/27/2021 6:30 AM
Contacts	Signed By	Update	Profile Change Request	Williams, Staci J Controller/Interim CFO Arkansas Methodist Medical Center 8702397855	Williams, Staci J Controller Arkansas Methodist Medical Center 8702397855	4/27/2021 6:30 AM
Details	State	Update		Approved	Active	4/1/2021 12:01 AM
Addresses	Main Address	Update	Change Request	1000 W KINGSHIGHWAY STE 14 AMMC PHYSICIAN GROUP PARAGOULD, AR 72450-4197	1110 W KINGSHIGHWAY AMMC Family Practice PARAGOULD, AR 72450-4197	3/11/2021 1:20 PM
Addresses	Billing Address	Insert	Change Request		AMMC Physician Group 1000 W Kingshighway, Ste 14 Paragould, AR 72450-4197	3/11/2021 1:20 PM
Contacts	Signed By	Insert	New Registration		Williams, Staci J Controller/Interim CFO Arkansas Methodist Medical Center 8702397855	3/5/2021 3:24 PM
Details	340B ID	Update	New Registration		RRC040039-01	3/5/2021 3:24 PM
Details	Entity Subname	Update	New Registration	ARKANSAS METHODIST HOSPITAL CORP	ARKANSAS METHODIST HOSPITAL CORP - Family Practice	3/5/2021 3:24 PM
Dates	Participating Approval Date	Update	New Registration		3/5/2021 3:24:29 PM	3/5/2021 3:24 PM
Details	State	Update	New Registration	Pending	Approved	3/5/2021 3:24 PM
Dates	Signed By Date	Update	New Registration		1/14/2021 1:42:59 PM	3/5/2021 3:24 PM
Dates	Start Date	Update	New Registration		4/1/2021 12:00:00 AM	3/5/2021 3:24 PM
Addresses	Main Address	Insert	New Registration		1000 W KINGSHIGHWAY STE 14 AMMC PHYSICIAN GROUP PARAGOULD, AR 72450-4197	1/13/2021 11:46 AM
Contacts	Authorizing Official	Insert	New Registration		Williams, Staci J Controller/Interim CFO Arkansas Methodist Medical Center 8702397855	1/13/2021 11:46 AM
Contacts	Primary Contact	Insert	New Registration		Carmack, Stan Pharm.D. Arkansas Methodist Medical Center 8702397861	1/13/2021 11:46 AM
Details	Assistance Received From Date	Insert	New Registration			1/13/2021 11:46 AM
Details	Assistance Received To Date	Insert	New Registration			1/13/2021 11:46 AM
Details	Last Recertification Date	Insert	New Registration			1/13/2021 11:46 AM
Details	Grant Number	Insert	New Registration			1/13/2021 11:46 AM
Details	340B ID	Insert	New Registration			1/13/2021 11:46 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2021 11:46 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2021 11:46 AM
Details	Medicare Provider Number	Insert	New Registration		040039	1/13/2021 11:46 AM
Details	Entity Name	Insert	New Registration		Arkansas Methodist Medical Center	1/13/2021 11:46 AM
Details	NOFO Number	Insert	New Registration			1/13/2021 11:46 AM
Details	Program Code	Insert	New Registration		RRC	1/13/2021 11:46 AM
Details	Entity Subname	Insert	New Registration		ARKANSAS METHODIST HOSPITAL CORP	1/13/2021 11:46 AM
Dates	Participating Approval Date	Insert	New Registration			1/13/2021 11:46 AM
Details	State	Insert	New Registration		Pending	1/13/2021 11:46 AM
Dates	Registration Date	Insert	New Registration		1/13/2021 11:46:06 AM	1/13/2021 11:46 AM
Dates	Signed By Date	Insert	New Registration			1/13/2021 11:46 AM
Dates	Start Date	Insert	New Registration			1/13/2021 11:46 AM
Terminations	Termination Comments	Insert	New Registration			1/13/2021 11:46 AM
Terminations	Termination Date	Insert	New Registration			1/13/2021 11:46 AM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2021 11:46 AM
Terminations	Termination Reason	Insert	New Registration			1/13/2021 11:46 AM