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KANSAS PHARMACY, LLC
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
KANSAS PHARMACY, LLC
Pharmacy Address
1119 E TULSA AVE
KANSAS, OK 74347-7055
Pharmacy Comments
Contract Details
Approval Date
2/16/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Contract Pharmacy Representative
Kansas Pharmacy
Drew Turner, Owner
(918) 868-6162
Signed By Date
2/9/2018
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