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OKLAHOMA CVS PHARMACY, L.L.C.
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
OKLAHOMA CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16736
13924 N PENNSYLVANIA AVE
OKLAHOMA CITY, OK 73134
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Chris Hammes, Executive Vice President
(405) 949-3400
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2022
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