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DSH440002A JACKSON-MADISON COUNTY GENERAL HOSP (Active)
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Main Details
Name
JACKSON-MADISON COUNTY GENERAL HOSP
Subdivision Name
WEST TENNESSEE SURGERY CENTER
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH440002A
Medicare Provider Number
440002
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/14/2022
Participating Start Date
7/1/2022
Participating Approval Date
5/24/2022
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
700 West Forest Ave. Suite 100
JACKSON, TN 38301
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 4/1/2016, terminated 1/1/2018. Reinstated 4/1/2019.
02/05/2019
5/5/16Participated starting 10/1/2004, terminated 4/1/2013, reinstated 7/1/2016
05/05/2016
10/24/08 UPDATED ADDR (WAS 620 SKYLINE DRIVE); 10/23/08 UPDATED ADDR (WAS 637 SKYLINE DRIVE)
01/12/2010
May 2025
May 2025
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