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DSH370089 TAHLEQUAH CITY HOSPITAL (Active)
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Main Details
Name
TAHLEQUAH CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH370089
Medicare Provider Number
370089
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
8/15/2024
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
1400 E DOWNING
TAHLEQUAH, OK 74464
Billing Address
TAHLEQUAH CITY HOSPITAL
PO BOX 1008
TAHLEQUAH, OK 74465
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating start date: (10/1/2010) until terminated effective date: (04/1/2018), reinstatement effective date: (4/1/2023)
02/13/2023
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