Covered Entity Details

DSH370089B NORTHEASTERN HEALTH SYSTEM (Terminated) - information as of 6/16/2025 11:16:12 PM

Main Details

Name

NORTHEASTERN HEALTH SYSTEM

Subdivision Name

TAHLEQUAH MEDICAL GROUP-TAHLEQUAH CITY HOSPITAL

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH370089B

Medicare Provider Number

370089

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

12/10/2010

Participating Start Date

1/1/2011

Participating Approval Date

12/15/2010

Last Recertification Date

11/7/2017

Termination Date
Termination Reason

4/1/2018
DSH percentage below statutory minimum

Contacts

Authorizing Official

Northeastern Health System
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263

Primary Contact

Northeastern Health System
William Ray Potts, Director of Pharmacy
(918) 453-2356

Addresses

Street Address

1373 E. BOONE STREET
TAHLEQUAH, OK 74464

Billing Address

TAHLEQUAH CITY HOSPITAL
P.O BOX 1008
TAHLEQUAH, OK 74465-1008

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
OK	200433420C,200433420D
		1881960771

Shipping Addresses

Shipping Address 1

TAHLEQUAH CITY HOSPITAL
1400 E. DOWNING
TAHLEQUAH, OK 74464

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH370089A	Child	DSH	NORTHEASTERN HEALTH SYSTEM	TAHLEQUAH MEDICAL GROUP BY-PASS 1	1201 E. ROSS BYPASS	TAHLEQUAH	OK	Terminated
DSH370089B	Child	DSH	NORTHEASTERN HEALTH SYSTEM	TAHLEQUAH MEDICAL GROUP-TAHLEQUAH CITY HOSPITAL	1373 E. BOONE STREET	TAHLEQUAH	OK	Terminated
DSH370089D	Child	DSH	NORTHEASTERN HEALTH SYSTEM	TAHLEQUAH MEDICAL GROUP-FORT GIBSON	104 LONE OAK CIRCLE	FORT GIBSON	OK	Terminated
DSH370089E	Child	DSH	NORTHEASTERN HEALTH SYSTEM	TAHLEQUAH MEDICAL GROUP-BY-PASS 2	1203 E. ROSS BYPASS	TAHLEQUAH	OK	Terminated
DSH370089F	Child	DSH	NORTHEASTERN HEALTH SYSTEM	TCH Infusion Clinic	228 N Bliss Avenue	Tahlequah	OK	Terminated
DSH370089G	Child	DSH	TAHLEQUAH CITY HOSPITAL	Tahlequah Medical Group - Urgent Care	1201 E Ross Bypass	Tahlequah	OK	Active
DSH370089H	Child	DSH	TAHLEQUAH CITY HOSPITAL	Northeastern Health System - Infusion Clinic	228 Bliss Avenue	Tahlequah	OK	Active
DSH370089J	Child	DSH	TAHLEQUAH CITY HOSPITAL	Fort Gibson Medical Clinic - Primary Care	104 Lone Oak Circle	Fort Gibson	OK	Active
DSH370089K	Child	DSH	TAHLEQUAH CITY HOSPITAL	Northeastern Health System - Surgery Clinic	205 Harris Circle	Tahlequah	OK	Active
DSH370089L	Child	DSH	TAHLEQUAH CITY HOSPITAL	NORTHEASTERN HEALTH SYSTEM - Heart Center	1373 E BOONE ST	TAHLEQUAH	OK	Active
DSH370089M	Child	DSH	TAHLEQUAH CITY HOSPITAL	Northeastern Health System - Nephrology Clinic	1373 E Boone St	Tahlequah	OK	Active
DSH370089N	Child	DSH	TAHLEQUAH CITY HOSPITAL	Northeastern Health System - Medicine Clinic	1373 E Boone St	Tahlequah	OK	Active
DSH370089P	Child	DSH	TAHLEQUAH CITY HOSPITAL	NORTHEASTERN HEALTH SYSTEM - Gastroenterology Clinic	205 HARRIS CIR	TAHLEQUAH	OK	Active
DSH370089Q	Child	DSH	TAHLEQUAH CITY HOSPITAL	Tahlequah Medical Group - Primary Care	1201 East Ross Bypass	Tahlequah	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/15/2018 12:00:00 AM	1/17/2018 10:41 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/17/2018 10:41 AM
Terminations	Termination Date	Update	Termination Request		4/1/2018 12:00:00 AM	1/17/2018 10:41 AM
Terminations	Termination Effective Date	Update	Termination Request		11/15/2017 12:00:00 AM	1/17/2018 10:41 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	1/17/2018 10:41 AM
Contacts	Primary Contact	Update	Recertification	POTTS, RAY DIRECTOR OF PHARMACY 9184532356	Potts, William Ray Director of Pharmacy Northeastern Health System 9184532356	11/7/2017 4:49 PM
Details	Last Recertification Date	Update	Recertification	9/7/2016 12:00:00 AM	11/7/2017 4:49:20 PM	11/7/2017 4:49 PM
Contacts	Authorizing Official	Update		BERRY, JAMES EXEC VICE PRESIDENT 9184532263	BERRY, JAMES EXEC VICE PRESIDENT Northeastern Health System 9184532263	11/7/2017 4:31 PM
Contacts	Authorizing Official	Update		WARD, JULIE VP OF FINANCE 9184532120	BERRY, JAMES EXEC VICE PRESIDENT 9184532263	9/11/2017 3:29 PM
Addresses	Main Address	Insert			1373 E. BOONE STREET TAHLEQUAH, OK 74464	9/7/2016 4:35 PM
Contacts	Authorizing Official	Insert			WARD, JULIE VP OF FINANCE 9184532120	9/7/2016 4:35 PM
Contacts	Primary Contact	Insert			POTTS, RAY DIRECTOR OF PHARMACY 9184532356	9/7/2016 4:35 PM
Details	Last Recertification Date	Update		8/26/2015 12:00:00 AM	9/7/2016 12:00:00 AM	9/7/2016 4:34 PM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/26/2015 12:00:00 AM	8/26/2015 4:28 PM
Addresses	Billing Address	Insert			TAHLEQUAH CITY HOSPITAL P.O BOX 1008 TAHLEQUAH, OK 74465-1008	11/10/2014 1:51 PM
Addresses	Shipping Address	Insert			TAHLEQUAH CITY HOSPITAL 1400 E. DOWNING TAHLEQUAH, OK 74464	11/10/2014 1:51 PM
Details	Entity Name	Update		TAHLEQUAH CITY HOSPITAL	NORTHEASTERN HEALTH SYSTEM	11/10/2014 1:50 PM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 1:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2014 7:16 AM
Medicaid Billing	Medicaid: Number	Insert			200433420C	4/22/2014 7:16 AM
Medicaid Billing	Medicaid: State	Insert			OK	4/22/2014 7:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2014 7:16 AM
Medicaid Billing	Medicaid: Number	Insert			200433420D	4/22/2014 7:16 AM
Medicaid Billing	Medicaid: State	Insert			OK	4/22/2014 7:16 AM
Medicaid Billing	NPI: Number	Insert			1881960771	4/22/2014 7:16 AM
Details	Last Recertification Date	Update		9/10/2013 8:29:14 PM	9/10/2013 12:00:00 AM	4/22/2014 7:16 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/10/2013 8:29:14 PM	9/10/2013 8:29 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/21/2012 7:28 AM
Details	Last Recertification Date	Insert				12/16/2010 11:48 AM
Details	Grant Number	Insert				12/16/2010 11:48 AM
Details	340B ID	Insert			DSH370089B	12/16/2010 11:48 AM
Details	Is Authorizing Official EHB Data	Insert				12/16/2010 11:48 AM
Dates	Last Date That 340B Drugs Purchased	Insert				12/16/2010 11:48 AM
Details	Medicare Provider Number	Insert			370089	12/16/2010 11:48 AM
Details	Entity Name	Insert			TAHLEQUAH CITY HOSPITAL	12/16/2010 11:48 AM
Details	Program Code	Insert			DSH	12/16/2010 11:48 AM
Details	Entity Subname	Insert			TAHLEQUAH MEDICAL GROUP-TAHLEQUAH CITY HOSPITAL	12/16/2010 11:48 AM
Dates	Participating Approval Date	Insert			12/15/2010 12:00:00 AM	12/16/2010 11:48 AM
Details	State	Insert			Active	12/16/2010 11:48 AM
Dates	Registration Date	Insert			12/10/2010 12:00:00 AM	12/16/2010 11:48 AM
Dates	Signed By Date	Insert			11/15/2010 12:00:00 AM	12/16/2010 11:48 AM
Dates	Start Date	Insert			1/1/2011 12:00:00 AM	12/16/2010 11:48 AM
Terminations	Termination Comments	Insert				12/16/2010 11:48 AM
Terminations	Termination Date	Insert				12/16/2010 11:48 AM
Terminations	Termination Effective Date	Insert				12/16/2010 11:48 AM
Terminations	Termination Reason	Insert				12/16/2010 11:48 AM