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INTEGRIS PHARMACY 4190
DSH370028 INTEGRIS BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
INTEGRIS BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370028
Entity Address
3300 NW EXPRESSWAY
OKLAHOMA CITY, OK 73112
Medicare Provider Number
370028
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
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
12/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rex P. Van Meter, COO
(405) 717-7963
Contract Pharmacy Representative
INTEGRIS Pro Health
Doug Smith, Executive VP
(405) 951-8204
Signed By Date
12/10/2019
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