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CAH251300-01 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL
Subdivision Name
Main Street Medical Clinic of Sebastopol
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH251300-01
Medicare Provider Number
251300
Outpatient Facility Provider Number
251300
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/8/2014
Last Recertification Date
9/1/2016
Termination Date
Termination Reason
10/1/2016
Site closure
Contacts
Authorizing Official
Lackey Memorial Hospital
sydney sawyer, ceo
(601) 469-4151 Ext: 301
Primary Contact
Lackey Memorial Hospital
Trent Lott, Pharmacist
(601) 469-4151 Ext: 391
Addresses
Street Address
17509 Highway 21
Sebastapol, MS 39359
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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