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WAL-MART PHARMACY 10-0081
SCH370089-00 NORTHEASTERN HEALTH SYSTEM
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Covered Entity Details
Entity Name
NORTHEASTERN HEALTH SYSTEM
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370089-00
Entity Address
1400 E. DOWNING
TAHLEQUAH, OK 74464
Medicare Provider Number
370089
Participating Start Date
4/1/2018
Last Recertification Date
9/8/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0081
Pharmacy Address
84127 HIGHWAY 59
STILWELL, OK 74960
Pharmacy Comments
Contract Details
Approval Date
1/19/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/19/2021
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