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DSH440002C JACKSON-MADISON COUNTY GENERAL HOSP (Active)
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Main Details
Name
JACKSON-MADISON COUNTY GENERAL HOSP
Subdivision Name
ALICE AND CARL KIRKLAND CANCER CTR - Cancer
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH440002C
Medicare Provider Number
440002
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/13/2022
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
720 WEST FOREST AVENUE
JACKSON, TN 38301-3901
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (4/1/2019) until terminated effective date: (1/1/2022), reinstatement effective dated: (07/01/2022)
05/23/2022
May 2025
May 2025
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