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INTEGRIS PHARMACY 4175
DSH370113 INTEGRIS GROVE HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS GROVE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370113
Entity Address
1001 EAST 18TH STREET
GROVE, OK 74344
Medicare Provider Number
370113
Participating Start Date
1/1/2022
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
INTEGRIS PHARMACY 4175
Pharmacy Address
601 E 13TH ST STE B
GROVE, OK 74344
Pharmacy Comments
Contract Details
Approval Date
7/11/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Contract Pharmacy Representative
INTEGRIS Health
Michael L. Weed, Chief Financial Officer
(801) 731-1467
Signed By Date
7/11/2023
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