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SCH370089-02 NORTHEASTERN HEALTH SYSTEM (Terminated)
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Main Details
Name
NORTHEASTERN HEALTH SYSTEM
Subdivision Name
NORTHEASTERN HEALTH SYSTEM - Surgery Clinic
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH370089-02
Medicare Provider Number
370089
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
2/7/2018
Participating Start Date
4/1/2018
Participating Approval Date
2/16/2018
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
205 HARRIS CIRCLE
SURGEON OFFICE
TAHLEQUAH, OK 74464-3354
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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