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INTEGRIS PHARMACY 4176
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
INTEGRIS PHARMACY 4176
Pharmacy Address
3300 NW EXPRESSWAY STE 1D1191
OKLAHOMA CITY, OK 73112-4418
Pharmacy Comments
Contract Details
Approval Date
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James D. Moore, President
(405) 636-7690
Contract Pharmacy Representative
INTEGRIS Health
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Signed By Date
1/4/2016
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