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INTEGRIS PHARMACY 4188
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 4188
Pharmacy Address
5915 W. MEMORIAL RD, STE 110
OKLAHOMA CITY, OK 73142
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tim Bowen, President
(918) 787-3400
Contract Pharmacy Representative
INTEGRIS Health
Georg F. Lunday, Chief Pharmacy Officer
(405) 401-4842
Signed By Date
10/17/2016
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