Covered Entity Details

DSH370089J TAHLEQUAH CITY HOSPITAL (Active) - information as of 4/25/2025 8:33:05 PM

Main Details

Name

TAHLEQUAH CITY HOSPITAL

Subdivision Name

Fort Gibson Medical Clinic - Primary Care

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH370089J

Medicare Provider Number

370089

Outpatient Facility Provider Number

378501

Additional Details

Current Program Status

Active

Registration Date

1/17/2023

Participating Start Date

4/1/2023

Participating Approval Date

3/6/2023

Last Recertification Date

8/16/2024

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

104 Lone Oak Circle
Fort Gibson, OK 74434

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	100700680K	1013458652

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
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	Last Recertification Date	Update	Recertification	9/10/2023 10:06:04 PM	8/16/2024 10:51:56 AM	8/16/2024 10:51 AM
Details	Last Recertification Date	Update	Recertification		9/10/2023 10:06:04 PM	9/10/2023 10:06 PM
Details	State	Update		Approved	Active	4/1/2023 12:01 AM
Addresses	Main Address	Insert	New Registration		104 Lone Oak Circle Fort Gibson, OK 74434	3/6/2023 4:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	3/6/2023 4:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100700680K	3/6/2023 4:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	3/6/2023 4:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013458652	3/6/2023 4:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	3/6/2023 4:34 PM
Contacts	Signed By	Insert	New Registration		BERRY, JAMES EXEC VICE PRESIDENT Northeastern Health System 9184532263	3/6/2023 4:34 PM
Details	340B ID	Update	New Registration		DSH370089J	3/6/2023 4:34 PM
Details	Entity Subname	Update	New Registration	Fort Gibson Medical Clinic	Fort Gibson Medical Clinic - Primary Care	3/6/2023 4:34 PM
Dates	Participating Approval Date	Update	New Registration		3/6/2023 4:34:40 PM	3/6/2023 4:34 PM
Details	State	Update	New Registration	Pending	Approved	3/6/2023 4:34 PM
Dates	Signed By Date	Update	New Registration		1/30/2023 4:56:23 PM	3/6/2023 4:34 PM
Dates	Start Date	Update	New Registration		4/1/2023 12:00:00 AM	3/6/2023 4:34 PM
Addresses	Main Address	Insert	New Registration		104 Lone Oak Circle Fort Gibson, OK 74434	1/17/2023 6:56 PM
Contacts	Authorizing Official	Insert	New Registration		BERRY, JAMES EXEC VICE PRESIDENT Northeastern Health System 9184532263	1/17/2023 6:56 PM
Contacts	Primary Contact	Insert	New Registration		Larmon, Stacie Ann Director of Pharmacy Northeastern Health System 9184532355-4562	1/17/2023 6:56 PM
Details	Assistance Received From Date	Insert	New Registration			1/17/2023 6:56 PM
Details	Assistance Received To Date	Insert	New Registration			1/17/2023 6:56 PM
Details	Last Recertification Date	Insert	New Registration			1/17/2023 6:56 PM
Details	Grant Number	Insert	New Registration			1/17/2023 6:56 PM
Details	340B ID	Insert	New Registration			1/17/2023 6:56 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/17/2023 6:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/17/2023 6:56 PM
Details	Medicare Provider Number	Insert	New Registration		370089	1/17/2023 6:56 PM
Details	Entity Name	Insert	New Registration		TAHLEQUAH CITY HOSPITAL	1/17/2023 6:56 PM
Details	NOFO Number	Insert	New Registration			1/17/2023 6:56 PM
Details	Program Code	Insert	New Registration		DSH	1/17/2023 6:56 PM
Details	Entity Subname	Insert	New Registration		Fort Gibson Medical Clinic	1/17/2023 6:56 PM
Dates	Participating Approval Date	Insert	New Registration			1/17/2023 6:56 PM
Details	State	Insert	New Registration		Pending	1/17/2023 6:56 PM
Dates	Registration Date	Insert	New Registration		1/17/2023 6:56:47 PM	1/17/2023 6:56 PM
Dates	Signed By Date	Insert	New Registration			1/17/2023 6:56 PM
Dates	Start Date	Insert	New Registration			1/17/2023 6:56 PM
Terminations	Termination Comments	Insert	New Registration			1/17/2023 6:56 PM
Terminations	Termination Date	Insert	New Registration			1/17/2023 6:56 PM
Terminations	Termination Effective Date	Insert	New Registration			1/17/2023 6:56 PM
Terminations	Termination Reason	Insert	New Registration			1/17/2023 6:56 PM