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WAL-MART PHARMACY 10-0028
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
WAL-MART PHARMACY 10-0028
Pharmacy Address
2415 N.W MAIN STREET
MIAMI, OK 74354
Pharmacy Comments
Contract Details
Approval Date
4/16/2014
Contract Begin Date
7/1/2014
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
Jordan Cash, President
(405) 636-7284
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/16/2014
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