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INTEGRIS PHARMACY 4174
DSH370028 INTEGRIS BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
INTEGRIS BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370028
Entity Address
3300 NW EXPRESSWAY
OKLAHOMA CITY, OK 73112
Medicare Provider Number
370028
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
INTEGRIS PHARMACY 4174
Pharmacy Address
1205 HEALTH CENTER PKWY STE 115
YUKON, OK 73099
Pharmacy Comments
Contract Details
Approval Date
1/21/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tim Johnsen, President
(405) 951-8110
Contract Pharmacy Representative
INTEGRIS Health
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Signed By Date
1/21/2016
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