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DSH260070B PEMISCOT COUNTY MEMORIAL HOSPITAL (Active)
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Main Details
Name
PEMISCOT COUNTY MEMORIAL HOSPITAL
Subdivision Name
Doctors Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH260070B
Medicare Provider Number
260070
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
3/4/2008
Participating Start Date
1/1/2015
Participating Approval Date
3/4/2008
Last Recertification Date
8/14/2024
Contacts
Authorizing Official
Pemiscot Memorial Health Systems
DAVID KETCHUM, CEO
(573) 359-3579
Primary Contact
PEMISCOT MEMORIAL HEALTH SYSTEMS
Loren Clifton, Pharmacy Technican
(573) 359-3612
Addresses
Street Address
106 W 12TH ST
CARUTHERSVILLE, MO 63830-1890
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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11/4/14;CE reinstated effective 1/1/15; was participating from 4/1/2008 to 9/30/13; not participating from 10/1/2013 to 12/30/14 due to failure to recertify
12/24/2014
April 2025
April 2025
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