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INTEGRIS PHARMACY 4190
DSH370028B INTEGRIS BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
INTEGRIS BAPTIST MEDICAL CENTER
Subdivision Name
INTEGRIS CANCER INSTITUTE OF OKLAHOMA (ICIO)
Type
Disproportionate Share Hospital
340B ID
DSH370028B
Entity Address
5911 WEST MEMORIAL ROAD
OKLAHOMA CITY, OK 73142
Medicare Provider Number
370028
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
INTEGRIS PHARMACY 4190
Pharmacy Address
3433 NW 56TH ST., STE 140B
OKLAHOMA CITY, OK 73112
Pharmacy Comments
2/13/12 UPDATED ADD (WAS 3443 NW 56TH ST)
Contract Details
Approval Date
11/25/2011
Contract Begin Date
11/25/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Chris Hammas, President & Managing Director of IBMC
(405) 949-3400
Contract Pharmacy Representative
Bruce C. Lawrence, President & CEO
(405) 949-3177
Signed By Date
11/11/2011
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