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WAL-MART PHARMACY 10-0090
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
WAL-MART PHARMACY 10-0090
Pharmacy Address
2115 S MAIN STREET
GROVE, OK 74344
Pharmacy Comments
Contract Details
Approval Date
7/12/2023
Contract Begin Date
10/1/2023
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
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/12/2023
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