Provider Demographics
NPI:1255497525
Name:INTEGRIS PROHEALTH INC
Entity Type:Organization
Organization Name:INTEGRIS PROHEALTH INC
Other - Org Name:INTEGRIS PHARMACY 4190
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:405-949-3120
Mailing Address - Street 1:3435 NW 56TH ST STE 301A
Mailing Address - Street 2:301-A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4448
Mailing Address - Country:US
Mailing Address - Phone:405-949-3120
Mailing Address - Fax:405-815-6445
Practice Address - Street 1:3433 NW 56TH ST
Practice Address - Street 2:STE 140B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4455
Practice Address - Country:US
Practice Address - Phone:405-945-4400
Practice Address - Fax:405-945-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
OK1-69013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100239970BMedicaid
OK100239970AMedicaid
2074201OtherPK
0595590001Medicare NSC