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INTEGRIS PHARMACY 4190
DSH370113 INTEGRIS GROVE HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS GROVE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370113
Entity Address
1001 EAST 18TH STREET
GROVE, OK 74344
Medicare Provider Number
370113
Participating Start Date
1/1/2022
Last Recertification Date
8/22/2024
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
10/24/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/8/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Greg Martin, President
(918) 786-2243
Contract Pharmacy Representative
Wentz Miller, Managing Director & C.F.O.
(405) 949-3172
Signed By Date
10/24/2013
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