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INTEGRIS PHARMACY 4190
DSH370211 INTEGRIS CANADIAN VALLEY HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS CANADIAN VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370211
Entity Address
1201 HEALTH CARE PARKWAY
YUKON, OK 73099
Medicare Provider Number
370211
Participating Start Date
4/1/2023
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
INTEGRIS PHARMACY 4190
Pharmacy Address
3433 NW 56TH ST., STE 140B
OKLAHOMA CITY, OK 73112
Pharmacy Comments
2/13/12 UPDATED ADD (WAS 3443 NW 56TH ST)
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Teresa Lynne Gray, President
(405) 717-7962
Contract Pharmacy Representative
INTEGRIS Health
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Signed By Date
7/15/2019
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