Provider Demographics
NPI:1275814337
Name:INTEGRIS PROHEALTH INC
Entity Type:Organization
Organization Name:INTEGRIS PROHEALTH INC
Other - Org Name:INTEGRIS PHARMACY 4187
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-359-4890
Mailing Address - Street 1:3435 NW 56TH ST STE 301A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4428
Mailing Address - Country:US
Mailing Address - Phone:405-713-7407
Mailing Address - Fax:405-815-6445
Practice Address - Street 1:4833 INTEGRIS PKWY
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-8864
Practice Address - Country:US
Practice Address - Phone:405-657-3900
Practice Address - Fax:405-471-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK1-68993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100710550BMedicaid
2131512OtherPK
OK100710550GMedicaid