Covered Entity Details

DSH370078A OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST (Terminated) - information as of 5/29/2025 1:58:04 AM

Main Details

Name

OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST

Subdivision Name

Oklahoma State University Medical Center - Outpatient Dialysis Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH370078A

Medicare Provider Number

370078

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/10/2020

Participating Start Date

4/1/2020

Participating Approval Date

3/3/2020

Last Recertification Date

8/21/2024

Termination Date
Termination Reason

4/1/2025
Site closure

Contacts

Authorizing Official

Oklahoma State University Medical Center
Eric Atkinson, Chief Financial Officer
(918) 599-5147

Primary Contact

Oklahoma State University Medical Center
John Bury, DIRECTOR OF PHARMACY
(918) 599-5565

Addresses

Street Address

744 West 9th St
Tulsa, OK 74127

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	200242900A	1578704938

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
DSH370078A	Child	DSH	OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST	Oklahoma State University Medical Center - Outpatient Dialysis Clinic	744 West 9th St	Tulsa	OK	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/24/2025 12:00:00 AM	1/30/2025 10:47 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/30/2025 10:47 AM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	1/30/2025 10:47 AM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2025 12:00:00 AM	1/30/2025 10:47 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	1/30/2025 10:47 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 5:10:39 PM	8/21/2024 8:04:33 AM	8/21/2024 8:04 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 10:38:26 AM	8/21/2023 5:10:39 PM	8/21/2023 5:10 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 6:09:43 PM	8/25/2022 10:38:26 AM	8/25/2022 10:38 AM
Contacts	Authorizing Official	Update	Change Request	Mathew, Finny President Oklahoma State University Medical Center 9185995900	Atkinson, Eric Chief Financial Officer Oklahoma State University Medical Center 9185995147	8/22/2022 3:25 PM
Contacts	Authorizing Official	Update	Change Request	Gutierrez, Noe Executive Director of Finance Oklahoma State University Medical Center 9185995900	Mathew, Finny President Oklahoma State University Medical Center 9185995900	2/11/2022 8:11 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 1:52:35 PM	8/24/2021 6:09:43 PM	8/24/2021 6:09 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1578704938 ( )		9/3/2020 1:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1578704938	9/3/2020 1:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/3/2020 1:52 PM
Details	Last Recertification Date	Update	Recertification		9/3/2020 1:52:35 PM	9/3/2020 1:52 PM
Contacts	Authorizing Official	Update	AO Change Request	Adams, Matt Administrator Oklahoma State University Medical Center 9185995908	Gutierrez, Noe Executive Director of Finance Oklahoma State University Medical Center 9185995900	8/31/2020 12:05 PM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Adams, Matt Administrator Oklahoma State University Medical Center 9185995908	3/3/2020 9:09 AM
Details	340B ID	Update	New Registration		DSH370078A	3/3/2020 9:09 AM
Details	Entity Name	Update	New Registration	OSU MEDICAL CENTER	OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST	3/3/2020 9:09 AM
Details	Entity Subname	Update	New Registration	Oklahoma State University Medical Center	Oklahoma State University Medical Center - Outpatient Dialysis Clinic	3/3/2020 9:09 AM
Dates	Participating Approval Date	Update	New Registration		3/3/2020 9:09:09 AM	3/3/2020 9:09 AM
Details	State	Update	New Registration	Pending	Approved	3/3/2020 9:09 AM
Dates	Signed By Date	Update	New Registration		1/12/2020 5:17:19 PM	3/3/2020 9:09 AM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	3/3/2020 9:09 AM
Addresses	Main Address	Insert	New Registration		744 West 9th St Tulsa, OK 74127	1/10/2020 1:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/10/2020 1:06 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		200242900A	1/10/2020 1:06 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	1/10/2020 1:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1578704938	1/10/2020 1:06 PM
Contacts	Primary Contact	Insert	New Registration		Bury, John DIRECTOR OF PHARMACY Oklahoma State University Medical Center 9185995565	1/10/2020 1:06 PM
Contacts	Authorizing Official	Insert	New Registration		Adams, Matt Administrator Oklahoma State University Medical Center 9185995908	1/10/2020 1:06 PM
Details	Last Recertification Date	Insert	New Registration			1/10/2020 1:06 PM
Details	Grant Number	Insert	New Registration			1/10/2020 1:06 PM
Details	340B ID	Insert	New Registration			1/10/2020 1:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/10/2020 1:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/10/2020 1:06 PM
Details	Medicare Provider Number	Insert	New Registration		370078	1/10/2020 1:06 PM
Details	Entity Name	Insert	New Registration		OSU MEDICAL CENTER	1/10/2020 1:06 PM
Details	Program Code	Insert	New Registration		DSH	1/10/2020 1:06 PM
Details	Entity Subname	Insert	New Registration		Oklahoma State University Medical Center	1/10/2020 1:06 PM
Dates	Participating Approval Date	Insert	New Registration			1/10/2020 1:06 PM
Details	State	Insert	New Registration		Pending	1/10/2020 1:06 PM
Dates	Registration Date	Insert	New Registration		1/10/2020 1:06:10 PM	1/10/2020 1:06 PM
Dates	Signed By Date	Insert	New Registration			1/10/2020 1:06 PM
Dates	Start Date	Insert	New Registration			1/10/2020 1:06 PM
Terminations	Termination Comments	Insert	New Registration			1/10/2020 1:06 PM
Terminations	Termination Date	Insert	New Registration			1/10/2020 1:06 PM
Terminations	Termination Effective Date	Insert	New Registration			1/10/2020 1:06 PM
Terminations	Termination Reason	Insert	New Registration			1/10/2020 1:06 PM