Covered Entity Details

PED463301-23 IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL (Active) - information as of 5/3/2025 11:30:43 PM

Main Details

Name

IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL

Subdivision Name

Endoscopy Lab - Endoscopy

Type

Children's Hospital

Rural

340B ID

PED463301-23

Medicare Provider Number

463301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/11/2024

Participating Start Date

4/1/2024

Participating Approval Date

1/30/2024

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Primary Children's Hospital
Sidney Norton, Finance AVP - Pediatrics
(801) 662-6277

Primary Contact

IHC Health Services, Inc.
Kevin Forbush, 340B Program Director
(385) 429-2887

Addresses

Street Address

2250 N. Miller Campus Drive
Lehi, UT 84043

Billing Address

IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL
100 NORTH MARIO CAPECCHI DRIVE
SALT LAKE CITY, UT 84113

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
UT		1235148594
ID		1235148594
CA		1235148594
IL		1235148594

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED463301-01	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	PRIMARY CHILDREN'S OUTPATIENT SURGICAL SERVICES	3773 WEST 12600 SOUTH	RIVERTON	UT	Active
PED463301-02	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Diabetes Clinic	81 North Mario Cappechi Drive	Salt Lake City	UT	Active
PED463301-03	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Safe and Healthy Families	81 North Mario Cappechi Drive	Salt Lake City	UT	Terminated
PED463301-04	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Child Residential and Day	5770 South 1500 West Building C	Salt Lake City	UT	Terminated
PED463301-05	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Adolescent Residential and Day	5770 South 1500 west Building A	Salt Lake City	UT	Terminated
PED463301-06	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Primary Children's outpatient clinic 138-428	100 north Mario Cappechi Drive	Salt Lake City	UT	Terminated
PED463301-07	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Spina Bifida Clinic 434	81 North Mario Capecchi Drive	Salt Lake City	UT	Terminated
PED463301-08	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Rehab Clinic 433	100 North Mario Capecchi Drive	Salt Lake City	UT	Terminated
PED463301-09	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Dialysis Clinic	81 North Mario Cappechi Drive	Salt Lake City	UT	Active
PED463301-10	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Cystic Fibrosis	81 N. Mario Capecchi Drive	Salt Lake City	UT	Active
PED463301-11	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Primary Children's Imaging Services Layton - Magnetic Resonance Imaging (MRI)	201 West Layton Parkway	Layton	UT	Terminated
PED463301-12	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Primary Children's Outpatient Imaging Services - Riverton - Magnetic Resonance Imaging (MRI)	3773 West 12600 South	Riverton	UT	Terminated
PED463301-13	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Primary Children's Hospital Colorectal Clinic - Colorectal Clinic	81 North Mario Capecchi Dr	Salt Lake City	UT	Terminated
PED463301-14	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	Primary Children's Hospital Craniofacial/Cleft Palate Clinic - Cleft Palate Clinic	81 North Mario Capecchi Dr.	Salt Lake City	UT	Terminated
PED463301-15	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Gender Management and Support - GEMS Clinic	81 North Mario Cappechi Drive	Salt Lake City	UT	Active
PED463301-16	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Day Treatment - Day Treatment	4387 Harrison Blvd. Suite C4	Ogden	UT	Active
PED463301-17	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Peds Comprehensive Care-Eccles - Peds Comprehensive Care Clinic	81 North Mario Cappechi Drive	SALT LAKE CITY	UT	Active
PED463301-18	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Physical Therapy - Peds Rehab-Riverton	3723 W 12600 S	RIVERTON	UT	Active
PED463301-19	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Outpatient Clinics - Physical Medicine and Rehab - Eccles	81 North Mario Cappechi Drive	SALT LAKE CITY	UT	Active
PED463301-20	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Physical Therapy - Peds Rehab - Layton	201 W Layton Pkwy	LAYTON	UT	Active
PED463301-21	Child	PED	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	PRIMARY CHILDREN'S OUTPATIENT SURGICAL SERVICES - RIVERTON SAME DAY SURGERY	3773 WEST 12600 SOUTH	RIVERTON	UT	Terminated
PED463301-22	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Outpatient Clinics - Pediatric Gynecology	81 North Mario Cappechi Drive	SALT LAKE CITY	UT	Active
PED463301-23	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Endoscopy Lab - Endoscopy	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-24	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Post Anesthesia Care Unit-PACU - Recovery Room	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-25	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Child Procedure Center - Operating Room	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-26	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Operating Rooms - Operating Room	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-27	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Emergency Department - Emergency	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-28	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Same Day Surgery - Surgical Services	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-29	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Diabetes Clinic - Pediatric Diabetes	2250 N. Miller Campus Drive	Lehi	UT	Active
PED463301-30	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Rapid Treatment Unit - Adults & Pediatrics	2250 N. Miller Campus Drive, Level 2, Pod 23	Lehi	UT	Active
PED463301-31	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatric Oncology - Oncology	2250 N. Miller Campus Drive, Level 3, Pod 31-32	Lehi	UT	Active
PED463301-32	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatric Clinics - Spine Center	2250 N. Miller Campus Drive, Level 2, Pod 23	Lehi	UT	Active
PED463301-33	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatric Clinics - Pediatric Cystic Fibrosis	2250 N. Miller Campus Drive, Level 2, Pod 22	Lehi	UT	Active
PED463301-35	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatric Clinics - Pediatric Rehab Medicine	2250 N. Miller Campus Drive, Level 1, Pod 12	Lehi	UT	Active
PED463301-36	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatric Clinics - Peds Comprehensive Care	2250 N. Miller Campus Drive, Level 1, Pod 12	Lehi	UT	Active
PED463301-37	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Neuromuscular clinic - Neuromuscular clinic	81 N. Mario Capecchi Dr	Salt Lake City	UT	Active
PED463301-38	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatrics Medical Genetics - Pediatrics Medical Genetics	81 N. Mario Capecchi Dr	Salt Lake City	UT	Active
PED463301-39	Child	PED	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	Pediatrics Medical Genetics - Pediatrics Medical Genetics	2250 N. Miller Campus Drive, Level 2, Pod 22	Lehi	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL	1/22/2025 12:34 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235148594	8/19/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/19/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235148594	8/19/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/19/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235148594	8/19/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/19/2024 4:02 PM
Details	Last Recertification Date	Update	Recertification		8/19/2024 4:02:42 PM	8/19/2024 4:02 PM
Contacts	Primary Contact	Update	Group Change Request	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	Forbush, Kevin 340B Program Director IHC Health Services, Inc. 3854292887	4/30/2024 7:43 AM
Addresses	Main Address	Update	Change Request	100 NORTH MARIO CAPECCHI DRIVE SALT LAKE CITY, UT 84113	2250 N. Miller Campus Drive Lehi, UT 84043	4/22/2024 2:34 PM
Addresses	Billing Address	Insert	Change Request		IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL 100 NORTH MARIO CAPECCHI DRIVE SALT LAKE CITY, UT 84113	4/22/2024 2:34 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Norton, Sidney Finance AVP - Pediatrics Primary Children's Hospital 8016626277	1/30/2024 7:26 AM
Details	340B ID	Update	New Registration		PED463301-23	1/30/2024 7:26 AM
Details	Entity Name	Update	New Registration	PRIMARY CHILDRENS HOSPITAL	IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL	1/30/2024 7:26 AM
Details	Entity Subname	Update	New Registration	Endoscopy Lab	Endoscopy Lab - Endoscopy	1/30/2024 7:26 AM
Dates	Participating Approval Date	Update	New Registration		1/30/2024 7:26:46 AM	1/30/2024 7:26 AM
Details	State	Update	New Registration	Pending	Approved	1/30/2024 7:26 AM
Dates	Signed By Date	Update	New Registration		1/12/2024 10:35:24 AM	1/30/2024 7:26 AM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	1/30/2024 7:26 AM
Addresses	Main Address	Insert	New Registration		100 NORTH MARIO CAPECCHI DRIVE SALT LAKE CITY, UT 84113	1/11/2024 6:26 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1235148594	1/11/2024 6:26 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	1/11/2024 6:26 PM
Contacts	Authorizing Official	Insert	New Registration		Norton, Sidney Finance AVP - Pediatrics Primary Children's Hospital 8016626277	1/11/2024 6:26 PM
Contacts	Primary Contact	Insert	New Registration		Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	1/11/2024 6:26 PM
Details	Assistance Received From Date	Insert	New Registration			1/11/2024 6:26 PM
Details	Assistance Received To Date	Insert	New Registration			1/11/2024 6:26 PM
Details	Last Recertification Date	Insert	New Registration			1/11/2024 6:26 PM
Details	Grant Number	Insert	New Registration			1/11/2024 6:26 PM
Details	340B ID	Insert	New Registration			1/11/2024 6:26 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/11/2024 6:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/11/2024 6:26 PM
Details	Medicare Provider Number	Insert	New Registration		463301	1/11/2024 6:26 PM
Details	Entity Name	Insert	New Registration		PRIMARY CHILDRENS HOSPITAL	1/11/2024 6:26 PM
Details	NOFO Number	Insert	New Registration			1/11/2024 6:26 PM
Details	Program Code	Insert	New Registration		PED	1/11/2024 6:26 PM
Details	Entity Subname	Insert	New Registration		Endoscopy Lab	1/11/2024 6:26 PM
Dates	Participating Approval Date	Insert	New Registration			1/11/2024 6:26 PM
Details	State	Insert	New Registration		Pending	1/11/2024 6:26 PM
Dates	Registration Date	Insert	New Registration		1/11/2024 6:26:55 PM	1/11/2024 6:26 PM
Dates	Signed By Date	Insert	New Registration			1/11/2024 6:26 PM
Dates	Start Date	Insert	New Registration			1/11/2024 6:26 PM
Terminations	Termination Comments	Insert	New Registration			1/11/2024 6:26 PM
Terminations	Termination Date	Insert	New Registration			1/11/2024 6:26 PM
Terminations	Termination Effective Date	Insert	New Registration			1/11/2024 6:26 PM
Terminations	Termination Reason	Insert	New Registration			1/11/2024 6:26 PM