340B Drug Pricing Program Database
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DSH370089J TAHLEQUAH CITY HOSPITAL (Active)
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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
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