Covered Entity Details

DSH440002L JACKSON-MADISON COUNTY GENERAL HOSP (Active) - information as of 5/1/2025 11:50:53 PM

Main Details

Name

JACKSON-MADISON COUNTY GENERAL HOSP

Subdivision Name

West Tennessee Healthcare North - Imaging - MRI

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH440002L

Medicare Provider Number

440002

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/14/2023

Participating Start Date

10/1/2023

Participating Approval Date

9/6/2023

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

West Tennessee Healthcare
Jeff Blankenship, CFO
(731) 541-6739

Primary Contact

West Tennessee Healthcare
Dan Wichlan, Director of Pharmacy
(731) 541-5918

Addresses

Street Address

367 Hospital Blvd
Jackson, TN 38305

Billing Address
Same as Street Address

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
TN	0440002	1093705428,1053011791
MS	01084764	1093705428
MO	010777506	1093705428
KY	01620541	1093705428

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
DSH440002A	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	WEST TENNESSEE SURGERY CENTER	700 West Forest Ave. Suite 100	JACKSON	TN	Active
DSH440002B	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	JACKSON MADISON COUNTY GENERAL HOSP - Humboldt Imaging	3525 CHERE CAROL RD	HUMBOLDT	TN	Terminated
DSH440002C	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	ALICE AND CARL KIRKLAND CANCER CTR - Cancer	720 WEST FOREST AVENUE	JACKSON	TN	Active
DSH440002D	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	JACKSON MADISON COUNTY GENERAL HOSP - Humboldt Emergency Department	3525 CHERE CAROL RD	HUMBOLDT	TN	Terminated
DSH440002E	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	Skyline Endoscopy Clinic - gastrointestinal	27 Medical Center Drive	Jackson	TN	Terminated
DSH440002F	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	WEST TENNESSEE IMAGING CENTER - Radiology	300 COATSLAND DRIVE	JACKSON	TN	Active
DSH440002G	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	WEST TENNESSEE HEALTHCARE NORTH - Surgery	367 HOSPITAL BLVD	JACKSON	TN	Active
DSH440002H	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	WEST TENNESSEE HEALTHCARE NORTH - Emergency Department	367 HOSPITAL BLVD	JACKSON	TN	Active
DSH440002J	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	WEST TENNESSEE HEALTHCARE NORTH - Imaging	367 HOSPITAL BLVD	JACKSON	TN	Active
DSH440002K	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	WEST TENNESSEE HEALTHCARE NORTH - Anesthesia	367 HOSPITAL BLVD	JACKSON	TN	Active
DSH440002L	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	West Tennessee Healthcare North - Imaging - MRI	367 Hospital Blvd	Jackson	TN	Active
DSH440002M	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	West Tennessee Imaging Center - CT Scan	300 Coatsland Drive	Jackson	TN	Active
DSH440002N	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	West Tennessee Imaging Center - MRI	300 Coatsland Drive	Jackson	TN	Active
DSH440002P	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	West Tennessee Healthcare North - Imaging - CT Scan	367 Hospital Blvd	Jackson	TN	Active
DSH440002Q	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	Alice and Carl Kirkland Cancer Center North - Oncology	322 Hospital Blvd	Jackson	TN	Active
DSH440002R	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	Alice and Carl Kirkland Cancer Center North Clinic - Oncology	322 Hospital Blvd	Jackson	TN	Active
DSH440002S	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	Alice and Carl Kirkland Cancer Center Clinic - Oncology	720 West Forest Ave	Jackson	TN	Active
DSH440002T	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	Infusion Clinic - Infusion Clinic Intravenous Therapy	8 Medical Center Drive	Jackson	TN	Active
DSH440002U	Child	DSH	JACKSON-MADISON COUNTY GENERAL HOSP	Infectious Disease - Infectious Disease Clinic	8 Medical Center Drive	Jackson	TN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Wichlan, Dan Assistant Director of Pharmacy West Tennessee Healthcare 7315415918	Wichlan, Dan Director of Pharmacy West Tennessee Healthcare 7315415918	4/23/2025 11:35 AM
Contacts	Primary Contact	Update	Change Request	Osborne, Sherry Executive Director of Pharmacy West Tn Healthcare 7315416229	Wichlan, Dan Assistant Director of Pharmacy West Tennessee Healthcare 7315415918	1/16/2025 7:49 AM
Details	Last Recertification Date	Update	Recertification		8/29/2024 11:00:14 AM	8/29/2024 11:00 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1053011791	6/28/2024 7:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	6/28/2024 7:55 PM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Blankenship, Jeff CFO West Tennessee Healthcare 7315416739	9/6/2023 12:59 PM
Details	340B ID	Update	New Registration		DSH440002L	9/6/2023 12:59 PM
Details	Entity Subname	Update	New Registration	West Tennessee Healthcare North - Imaging	West Tennessee Healthcare North - Imaging - MRI	9/6/2023 12:59 PM
Dates	Participating Approval Date	Update	New Registration		9/6/2023 12:59:11 PM	9/6/2023 12:59 PM
Details	State	Update	New Registration	Pending	Approved	9/6/2023 12:59 PM
Dates	Signed By Date	Update	New Registration		7/14/2023 4:34:05 PM	9/6/2023 12:59 PM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	9/6/2023 12:59 PM
Addresses	Main Address	Insert	New Registration		367 Hospital Blvd Jackson, TN 38305	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0440002	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01084764	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010777506	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01620541	7/14/2023 4:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	7/14/2023 4:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093705428	7/14/2023 4:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	7/14/2023 4:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093705428	7/14/2023 4:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	7/14/2023 4:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093705428	7/14/2023 4:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	7/14/2023 4:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093705428	7/14/2023 4:14 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/14/2023 4:14 PM
Contacts	Authorizing Official	Insert	New Registration		Blankenship, Jeff CFO West Tennessee Healthcare 7315416739	7/14/2023 4:14 PM
Contacts	Primary Contact	Insert	New Registration		Osborne, Sherry Executive Director of Pharmacy West Tn Healthcare 7315416229	7/14/2023 4:14 PM
Details	Assistance Received From Date	Insert	New Registration			7/14/2023 4:14 PM
Details	Assistance Received To Date	Insert	New Registration			7/14/2023 4:14 PM
Details	Last Recertification Date	Insert	New Registration			7/14/2023 4:14 PM
Details	Grant Number	Insert	New Registration			7/14/2023 4:14 PM
Details	340B ID	Insert	New Registration			7/14/2023 4:14 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/14/2023 4:14 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/14/2023 4:14 PM
Details	Medicare Provider Number	Insert	New Registration		440002	7/14/2023 4:14 PM
Details	Entity Name	Insert	New Registration		JACKSON-MADISON COUNTY GENERAL HOSP	7/14/2023 4:14 PM
Details	NOFO Number	Insert	New Registration			7/14/2023 4:14 PM
Details	Program Code	Insert	New Registration		DSH	7/14/2023 4:14 PM
Details	Entity Subname	Insert	New Registration		West Tennessee Healthcare North - Imaging	7/14/2023 4:14 PM
Dates	Participating Approval Date	Insert	New Registration			7/14/2023 4:14 PM
Details	State	Insert	New Registration		Pending	7/14/2023 4:14 PM
Dates	Registration Date	Insert	New Registration		7/14/2023 4:14:30 PM	7/14/2023 4:14 PM
Dates	Signed By Date	Insert	New Registration			7/14/2023 4:14 PM
Dates	Start Date	Insert	New Registration			7/14/2023 4:14 PM
Terminations	Termination Comments	Insert	New Registration			7/14/2023 4:14 PM
Terminations	Termination Date	Insert	New Registration			7/14/2023 4:14 PM
Terminations	Termination Effective Date	Insert	New Registration			7/14/2023 4:14 PM
Terminations	Termination Reason	Insert	New Registration			7/14/2023 4:14 PM