Provider Demographics
NPI:1093133241
Name:INTEGRIS PROHEALTH INC
Entity type:Organization
Organization Name:INTEGRIS PROHEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
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 1:3300 NW EXPRESSWAY STE 1D1191
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-951-2345
Practice Address - Fax:405-951-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK1-68963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100710550CMedicaid
OK100710550FMedicaid
2145259OtherPK