Provider Demographics
NPI:1952796682
Name:INTEGRIS PROHEALTH INC
Entity Type:Organization
Organization Name:INTEGRIS PROHEALTH INC
Other - Org Name:INTEGRIS PHARMACY 4174
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:
Authorized Official - Phone:405-949-3120
Mailing Address - Street 1:3435 NW 56TH ST STE 301A
Mailing Address - Street 2:SUITE 301A
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 1:1205 HEALTH CENTER PKWY STE 115
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6396
Practice Address - Country:US
Practice Address - Phone:405-717-5330
Practice Address - Fax:405-717-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK26-71973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150930OtherPK
OK0595590008Medicare NSC
OK100710550IMedicaid