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SCH370089-00 NORTHEASTERN HEALTH SYSTEM (Terminated)
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Main Details
Name
NORTHEASTERN HEALTH SYSTEM
Subdivision Name
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH370089-00
Medicare Provider Number
370089
Additional Details
Current Program Status
Terminated
Registration Date
1/26/2018
Participating Start Date
4/1/2018
Participating Approval Date
2/16/2018
Last Recertification Date
9/8/2022
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
1400 E. DOWNING
TAHLEQUAH, OK 74464
Billing Address
TAHLEQUAH CITY HOSPITAL
1400 E. DOWNING
PO BOX 1008
TAHLEQUAH, OK 74465
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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