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WAL-MART PHARMACY 10-0564
DSH370211 INTEGRIS CANADIAN VALLEY HOSPITAL
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Covered Entity Details
Entity Name
INTEGRIS CANADIAN VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370211
Entity Address
1201 HEALTH CARE PARKWAY
YUKON, OK 73099
Medicare Provider Number
370211
Participating Start Date
4/1/2023
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0564
Pharmacy Address
6100 WEST RENO AVENUE
OKLAHOMA CITY (W), OK 73127
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
2/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rex P. Van Meter, COO
(405) 717-7963
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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