Provider Demographics
NPI:1629769393
Name:INTEGRIS PROHEALTH INC
Entity Type:Organization
Organization Name:INTEGRIS PROHEALTH INC
Other - Org Name:INTEGRIS PHARMACY 4175
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:AHLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-252-8501
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:405-949-3120
Mailing Address - Fax:405-815-6445
Practice Address - Street 1:601 E 13TH ST STE B
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2962
Practice Address - Country:US
Practice Address - Phone:405-949-3120
Practice Address - Fax:405-815-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100791460BMedicaid