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CAH251300-09 SE LACKEY CAH AND NURSING HOME (Terminated)
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Main Details
Name
SE LACKEY CAH AND NURSING HOME
Subdivision Name
MAIN STREET MEDICAL CLINIC OF MORTON
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH251300-09
Medicare Provider Number
251300
Outpatient Facility Provider Number
258570
Additional Details
Current Program Status
Terminated
Registration Date
10/14/2014
Participating Start Date
1/1/2015
Participating Approval Date
11/19/2014
Last Recertification Date
9/1/2016
Termination Date
Termination Reason
7/1/2017
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
347 SOUTH 4TH STREET
MORTON, MS 39117-3407
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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