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INTEGRIS PHARMACY 4174
DSH370211 INTEGRIS CANADIAN VALLEY HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS CANADIAN VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370211
Entity Address
1201 HEALTH CARE PARKWAY
YUKON, OK 73099
Medicare Provider Number
370211
Participating Start Date
4/1/2023
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
INTEGRIS PHARMACY 4174
Pharmacy Address
1205 HEALTH CENTER PKWY STE 115
YUKON, OK 73099
Pharmacy Comments
Contract Details
Approval Date
1/14/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Contract Pharmacy Representative
INTEGRIS Pro Health
Doug Smith, Executive VP
(405) 951-8204
Signed By Date
1/14/2023
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