Covered Entity Details

DSH460004B MCKAY-DEE HOSPITAL CENTER (Terminated) - information as of 5/17/2025 10:51:48 PM

Main Details

Name

MCKAY-DEE HOSPITAL CENTER

Subdivision Name

Layton Clinic Imaging Service

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH460004B

Medicare Provider Number

460004

Outpatient Facility Provider Number

460004

Additional Details

Current Program Status

Terminated

Registration Date

7/10/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/4/2014

Last Recertification Date

11/10/2017

Termination Date
Termination Reason

7/1/2018
DSH percentage below statutory minimum

Contacts

Authorizing Official

Intermountain Healthcare
Trever Porter, Finance Dir-MK
(801) 387-3767

Primary Contact

McKay-Dee Hospital , Intermountain Healthcare
Terrie Koehler, Region Director of Pharmacy
(801) 387-6002

Addresses

Street Address

2075 N 1200 West
Layton, UT 84041-1616

Billing Address

McKay-Dee Hospital Center
4401 Harrison Blvd
Ogden, UT 84403-3195

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	870269232274
AK	1005766
AZ	024737
AR	148293105
CO	95432514
FL	014726400
GA	003140736A
IL	942854057004
IN	003140736A
KS	100101240B
KY	01640168
LA	1764647
MS	00095778
NE	10026356301
NM	000A8978
NY	01496708
ND	2356
OH	0663170
OK	100706200A
OR	073056
PA	100773821 0033
SC	11857B
TN	1505886
WY	108302300
		1194749580

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
DSH460004A	Child	DSH	MCKAY-DEE HOSPITAL	Summit Day Treatment	4387 Harrison Blvd. Suite C4	Ogden	UT	Terminated
DSH460004B	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Layton Clinic Imaging Service	2075 N 1200 West	Layton	UT	Terminated
DSH460004C	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Physical Therapy-Layton	2075 North 1200 West	Layton	UT	Terminated
DSH460004D	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Physical Therapy Ortho - OP - McKay Dee Physical Therapy and Rehab	3895 Harrison Blvd	Ogden	UT	Terminated
DSH460004E	Child	DSH	MCKAY-DEE HOSPITAL	Anti-Coagulation Clinic - Anti-Coagulation Clinic	4421 Harrison Blvd.	Ogden	UT	Terminated
DSH460004F	Child	DSH	MCKAY-DEE HOSPITAL CENTER	Physical Therapy Complex - OP - Stewart Rehabilitation	3903 Harrison Blvd	Ogden	UT	Terminated
DSH460004G	Child	DSH	IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital	Infusion Center - Infusion Services	201 W Layton Pkwy Suite 2050	Layton	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Reinstatement	Gillespie, Kerry CFO-Specialty Based Care Intermountain Healthcare 8014422459	Porter, Trever Finance Dir-MK Intermountain Healthcare 8013873767	6/5/2020 12:13 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/30/2018 12:00:00 AM	6/1/2018 7:40 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/1/2018 7:40 AM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	6/1/2018 7:40 AM
Terminations	Termination Effective Date	Update	Termination Request		5/30/2018 12:00:00 AM	6/1/2018 7:40 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/1/2018 7:40 AM
Contacts	Authorizing Official	Update	Change Request	Smith, Douglas M. Regional CFO Intermountain Healthcare 8013873713	Gillespie, Kerry CFO-Specialty Based Care Intermountain Healthcare 8014422459	12/21/2017 8:17 AM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/10/2017 12:14:01 PM	11/10/2017 12:14 PM
Contacts	Primary Contact	Update		Koehler, Terrie Region Director of Pharmacy 8013876002	Koehler, Terrie Region Director of Pharmacy McKay-Dee Hospital , Intermountain Healthcare 8013876002	10/25/2017 9:24 PM
Contacts	Authorizing Official	Update		Smith, Douglas M. Regional CFO 8013873713	Smith, Douglas M. Regional CFO Intermountain Healthcare 8013873713	10/11/2017 1:12 PM
Contacts	Signed By	Update		Smith, Douglas M. Regional CFO 8013873713	Smith, Douglas M. Regional CFO Intermountain Healthcare 8013873713	10/11/2017 1:12 PM
Contacts	Authorizing Official	Insert			Smith, Douglas M. Regional CFO 8013873713	8/14/2017 8:33 PM
Contacts	Signed By	Insert			Smith, Douglas M. Regional CFO 8013873713	8/14/2017 8:33 PM
Contacts	Primary Contact	Insert			Koehler, Terrie Region Director of Pharmacy 8013876002	8/14/2017 8:13 PM
Addresses	Main Address	Insert			2075 N 1200 West Layton, UT 84041-1616	5/15/2017 4:38 PM
Addresses	Billing Address	Insert			McKay-Dee Hospital Center 4401 Harrison Blvd Ogden, UT 84403-3195	5/15/2017 4:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			95432514	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			CO	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			014726400	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			FL	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			003140736A	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			GA	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			942854057004	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			IL	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			003140736A	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			IN	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			100101240B	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			KS	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			01640168	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			KY	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			1764647	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			LA	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			00095778	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			MS	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			10026356301	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			NE	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			000A8978	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			NM	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			01496708	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			NY	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			2356	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			ND	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			0663170	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			OH	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			100706200A	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			OK	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			073056	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			OR	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			100773821 0033	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			PA	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			11857B	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			SC	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			1505886	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			TN	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			108302300	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			WY	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			1005766	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			AK	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			024737	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			AZ	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: Number	Insert			148293105	4/17/2017 4:56 PM
Medicaid Billing	Medicaid: State	Insert			AR	4/17/2017 4:56 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 5:01 PM
Details	Last Recertification Date	Update			8/24/2015 12:00:00 AM	8/24/2015 11:43 AM
Dates	Participating Approval Date	Update			9/4/2014 12:00:00 AM	9/4/2014 12:38 PM
Details	State	Update		Pending	Active	9/4/2014 12:38 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/4/2014 12:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45143	DSH460004B	9/3/2014 2:44 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45143	7/10/2014 7:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/10/2014 7:03 PM
Medicaid Billing	Medicaid: Number	Insert			870269232274	7/10/2014 7:03 PM
Medicaid Billing	Medicaid: State	Insert			UT	7/10/2014 7:03 PM
Medicaid Billing	NPI: Number	Insert			1194749580	7/10/2014 7:03 PM
Details	Last Recertification Date	Insert				7/10/2014 7:03 PM
Details	Grant Number	Insert				7/10/2014 7:03 PM
Details	340B ID	Insert				7/10/2014 7:03 PM
Details	Is Authorizing Official EHB Data	Insert				7/10/2014 7:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/10/2014 7:03 PM
Details	Medicare Provider Number	Insert			460004	7/10/2014 7:03 PM
Details	Entity Name	Insert			MCKAY-DEE HOSPITAL CENTER	7/10/2014 7:03 PM
Details	Program Code	Insert			DSH	7/10/2014 7:03 PM
Details	Entity Subname	Insert			Layton Clinic Imaging Service	7/10/2014 7:03 PM
Dates	Participating Approval Date	Insert				7/10/2014 7:03 PM
Details	State	Insert			Pending	7/10/2014 7:03 PM
Dates	Registration Date	Insert			7/10/2014 12:00:00 AM	7/10/2014 7:03 PM
Dates	Signed By Date	Insert			7/10/2014 12:00:00 AM	7/10/2014 7:03 PM
Dates	Start Date	Insert				7/10/2014 7:03 PM
Terminations	Termination Comments	Insert				7/10/2014 7:03 PM
Terminations	Termination Date	Insert				7/10/2014 7:03 PM
Terminations	Termination Effective Date	Insert				7/10/2014 7:03 PM
Terminations	Termination Reason	Insert				7/10/2014 7:03 PM