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WAL-MART PHARMACY 10-0389
DSH370106 INTEGRIS SOUTH OKLAHOMA CITY HOSPITAL CORPORATION
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Covered Entity Details
Entity Name
INTEGRIS SOUTH OKLAHOMA CITY HOSPITAL CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370106
Entity Address
4401 SOUTH WESTERN AVE
OKLAHOMA CITY, OK 73109
Medicare Provider Number
370106
Participating Start Date
7/1/2009
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0389
Pharmacy Address
1225 W I-35 FRONTAGE RD
EDMOND, OK 73034
Pharmacy Comments
Contract Details
Approval Date
4/17/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James D. Moore, President
(405) 636-7690
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/17/2014
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