Covered Entity Details

SCH370089-08 NORTHEASTERN HEALTH SYSTEM (Terminated) - information as of 5/20/2025 11:45:44 PM

Main Details

Name

NORTHEASTERN HEALTH SYSTEM

Subdivision Name

Tahlequah Medical Group Primary Care - Primary Care

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH370089-08

Medicare Provider Number

370089

Outpatient Facility Provider Number

378503

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2018

Participating Start Date

7/1/2018

Participating Approval Date

6/5/2018

Last Recertification Date

9/7/2022

Termination Date
Termination Reason

4/1/2023
Change of covered entity type

Contacts

Authorizing Official

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

Primary Contact

Northeastern Health System
Stacie Ann Larmon, Director of Pharmacy
(918) 453-2355 Ext: 4562

Addresses

Street Address

1201 East Ross Bypass
Tahlequah, OK 74464

Billing Address
Same as Street Address

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	100700680A	1306387949

Shipping Addresses

Same as Street Address

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
SCH370089-01	Child	SCH	NORTHEASTERN HEALTH SYSTEM	NORTHEASTERN HEALTH SYSTEM - Heart Center	1373 E BOONE ST, STE 3400	TAHLEQUAH	OK	Terminated
SCH370089-02	Child	SCH	NORTHEASTERN HEALTH SYSTEM	NORTHEASTERN HEALTH SYSTEM - Surgery Clinic	205 HARRIS CIRCLE	TAHLEQUAH	OK	Terminated
SCH370089-03	Child	SCH	NORTHEASTERN HEALTH SYSTEM	NORTHEASTERN HEALTH SYSTEM - GASTROENTEROLOGY CLINIC	205 HARRIS CIRCLE	TAHLEQUAH	OK	Terminated
SCH370089-04	Child	SCH	NORTHEASTERN HEALTH SYSTEM	NORTHEASTERN HEALTH SYSTEM - Medicine Clinic	1373 E BOONE ST, STE 2300	TAHLEQUAH	OK	Terminated
SCH370089-05	Child	SCH	NORTHEASTERN HEALTH SYSTEM	NORTHEASTERN HEALTH SYSTEM - INFUSION CLINIC	228 BLISS AVENUE	TAHLEQUAH	OK	Terminated
SCH370089-06	Child	SCH	NORTHEASTERN HEALTH SYSTEM	NORTHEASTERN HEALTH SYSTEM - NEPHROLOGY CLINIC	1373 East Boone Street	Tahlequah	OK	Terminated
SCH370089-07	Child	SCH	NORTHEASTERN HEALTH SYSTEM	Fort Gibson Medical Clinic - Primary Care	104 Lone Oak Circle	Ft. Gibson	OK	Terminated
SCH370089-08	Child	SCH	NORTHEASTERN HEALTH SYSTEM	Tahlequah Medical Group Primary Care - Primary Care	1201 East Ross Bypass	Tahlequah	OK	Terminated
SCH370089-09	Child	SCH	NORTHEASTERN HEALTH SYSTEM	Urgent Care - Primary Care	1203 East Ross Bypass	Tahlequah	OK	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2023 12:00:00 AM	3/6/2023 8:59 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	3/6/2023 8:59 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2023 12:00:00 AM	3/6/2023 8:59 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2023 12:00:00 AM	3/6/2023 8:59 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	3/6/2023 8:59 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 10:42:47 AM	9/7/2022 12:22:18 PM	9/7/2022 12:22 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 12:11:54 PM	9/9/2021 10:42:47 AM	9/9/2021 10:42 AM
Medicaid Billing	NPI: State	Update	Recertification		OK	9/9/2020 12:11 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 2:55:51 PM	9/9/2020 12:11:54 PM	9/9/2020 12:11 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 3:50:03 PM	8/21/2019 2:55:51 PM	8/21/2019 2:55 PM
Details	Last Recertification Date	Update	Recertification		8/22/2018 3:50:03 PM	8/22/2018 3:50 PM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		BERRY, JAMES EXEC VICE PRESIDENT Northeastern Health System 9184532263	6/5/2018 8:56 AM
Details	340B ID	Update	New Registration		SCH370089-08	6/5/2018 8:56 AM
Details	Entity Subname	Update	New Registration	Tahlequah Medical Group Primary Care	Tahlequah Medical Group Primary Care - Primary Care	6/5/2018 8:56 AM
Dates	Participating Approval Date	Update	New Registration		6/5/2018 8:56:31 AM	6/5/2018 8:56 AM
Details	State	Update	New Registration	Pending	Approved	6/5/2018 8:56 AM
Dates	Signed By Date	Update	New Registration		4/12/2018 5:11:14 PM	6/5/2018 8:56 AM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	6/5/2018 8:56 AM
Addresses	Main Address	Insert	New Registration		1201 East Ross Bypass Tahlequah, OK 74464	4/12/2018 5:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2018 5:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100700680A	4/12/2018 5:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	4/12/2018 5:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1306387949	4/12/2018 5:11 PM
Contacts	Authorizing Official	Insert	New Registration		BERRY, JAMES EXEC VICE PRESIDENT Northeastern Health System 9184532263	4/12/2018 5:11 PM
Contacts	Primary Contact	Insert	New Registration		Larmon, Stacie Ann Director of Pharmacy Northeastern Health System 9184532355-4562	4/12/2018 5:11 PM
Details	Last Recertification Date	Insert	New Registration			4/12/2018 5:11 PM
Details	Grant Number	Insert	New Registration			4/12/2018 5:11 PM
Details	340B ID	Insert	New Registration			4/12/2018 5:11 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2018 5:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2018 5:11 PM
Details	Medicare Provider Number	Insert	New Registration		370089	4/12/2018 5:11 PM
Details	Entity Name	Insert	New Registration		NORTHEASTERN HEALTH SYSTEM	4/12/2018 5:11 PM
Details	Program Code	Insert	New Registration		SCH	4/12/2018 5:11 PM
Details	Entity Subname	Insert	New Registration		Tahlequah Medical Group Primary Care	4/12/2018 5:11 PM
Dates	Participating Approval Date	Insert	New Registration			4/12/2018 5:11 PM
Details	State	Insert	New Registration		Pending	4/12/2018 5:11 PM
Dates	Registration Date	Insert	New Registration		4/12/2018 5:11:12 PM	4/12/2018 5:11 PM
Dates	Signed By Date	Insert	New Registration			4/12/2018 5:11 PM
Dates	Start Date	Insert	New Registration			4/12/2018 5:11 PM
Terminations	Termination Comments	Insert	New Registration			4/12/2018 5:11 PM
Terminations	Termination Date	Insert	New Registration			4/12/2018 5:11 PM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2018 5:11 PM
Terminations	Termination Reason	Insert	New Registration			4/12/2018 5:11 PM