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OKLAHOMA CVS PHARMACY, L.L.C.
DSH370106 INTEGRIS SOUTH OKLAHOMA CITY HOSPITAL CORPORATION
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Covered Entity Details
Entity Name
INTEGRIS SOUTH OKLAHOMA CITY HOSPITAL CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370106
Entity Address
4401 SOUTH WESTERN AVE
OKLAHOMA CITY, OK 73109
Medicare Provider Number
370106
Participating Start Date
7/1/2009
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OKLAHOMA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08314
1040 SW 19TH ST.
MOORE, OK 73160
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
12/5/2022
Pharmacy closed
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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