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Walmart Pharmacy 10-7611
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
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
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
INTEGRIS Health
Ryan Dale Dooley, 340B Compliance Manager
(405) 802-6057
Signed By Date
10/9/2023
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