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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #10916
1621 S. DIVISION ST.
GUTHRIE, OK 73044
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/13/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Chris Hammes, Executive Vice President
(405) 949-3400
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/13/2020
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