Provider Demographics
NPI:1811405202
Name:INTEGRIS PROHEALTH INC
Entity Type:Organization
Organization Name:INTEGRIS PROHEALTH INC
Other - Org Name:THE CLINIC RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-949-3120
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 1:7301 SW 44TH ST # F
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-4308
Practice Address - Country:US
Practice Address - Phone:405-357-3510
Practice Address - Fax:405-357-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18106333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175308OtherPK