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WALGREEN CO.
DSH370004 INTEGRIS MIAMI HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS MIAMI HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370004
Entity Address
200 2ND AVE. SW
MIAMI, OK 74354
Medicare Provider Number
370004
Participating Start Date
1/1/2023
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07889
910 N MAIN STREET
MIAMI, OK 74354-3317
Pharmacy Comments
Contract Details
Approval Date
4/14/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/11/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOEL HART, PRESIDENT
(918) 540-7101
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/14/2013
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