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INTEGRIS PHARMACY 4188
SCH370113-00 INTEGRIS GROVE HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS GROVE HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370113-00
Entity Address
1001 EAST 18TH STREET
GROVE, OK 74344
Medicare Provider Number
370113
Participating Start Date
1/1/2020
Last Recertification Date
8/23/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
INTEGRIS PHARMACY 4188
Pharmacy Address
5915 W. MEMORIAL RD, STE 110
OKLAHOMA CITY, OK 73142
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jonas Rabel, President
(918) 540-7101
Contract Pharmacy Representative
INTEGRIS Pro Health
Doug Smith, Executive VP
(405) 951-8204
Signed By Date
10/16/2019
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