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TAHLEQUAH DRUG COMPANY
DSH370089 TAHLEQUAH CITY HOSPITAL
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Covered Entity Details
Entity Name
TAHLEQUAH CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370089
Entity Address
1400 E DOWNING
TAHLEQUAH, OK 74464
Medicare Provider Number
370089
Participating Start Date
4/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
TAHLEQUAH DRUG COMPANY
Pharmacy Address
DBA: TAHLEQUAH DRUG COMPANY
2028 MAHANEY AVE
TAHLEQUAH, OK 74464
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Contract Pharmacy Representative
Tahlequah Drug Compnay
Dennis Bird, Owner
(918) 431-0555
Signed By Date
7/14/2017
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