Covered Entity Details

CAH461307-01 IHC Health Services Inc. DBA Intermountain Health Heber Valley Hospital (Active) - information as of 5/13/2025 1:40:53 AM

Main Details

Name

IHC Health Services Inc. DBA Intermountain Health Heber Valley Hospital

Subdivision Name

Renal Dialysis

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH461307-01

Medicare Provider Number

461307

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/15/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/16/2015

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Heber Valley Hospital
Jennilyn Ferry, Finance Director
(435) 658-6709

Primary Contact

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

Addresses

Street Address

380 East 1500 South STE 101
Heber City, UT 84032

Billing Address

IHC Health Services Inc. DBA: Heber Valley Hospital
454 E Medical Way
Heber City, UT 84032

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		1770962771,1316055205

Shipping Addresses

Shipping Address 1

Heber Valley Hospital
454 E Medical Way
Heber City, UT 84032

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
CAH461307-01	Child	CAH	IHC Health Services Inc. DBA Intermountain Health Heber Valley Hospital	Renal Dialysis	380 East 1500 South STE 101	Heber City	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 12:41:05 PM	8/14/2024 9:42:31 AM	8/14/2024 9:42 AM
Details	Entity Name	Update	Change Request	IHC Health Services Inc. DBA: Heber Valley Hospital	IHC Health Services Inc. DBA Intermountain Health Heber Valley Hospital	5/7/2024 7:32 AM
Contacts	Primary Contact	Update	Change Request	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	Forbush, Kevin 340B Program Director IHC Health Services, Inc. 3854292887	5/2/2024 12:46 PM
Details	Last Recertification Date	Update	Recertification	8/25/2022 5:38:00 PM	8/17/2023 12:41:05 PM	8/17/2023 12:41 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 1:35:21 PM	8/25/2022 5:38:00 PM	8/25/2022 5:38 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 8:18:01 AM	8/25/2021 1:35:21 PM	8/25/2021 1:35 PM
Addresses	Shipping Address	Delete	Change Request	Heber Valley Hospital 1485 South Hwy 40 Heber City, UT 84032		3/4/2021 2:22 PM
Addresses	Shipping Address	Insert	Change Request		Heber Valley Hospital 454 E Medical Way Heber City, UT 84032	3/4/2021 2:22 PM
Addresses	Billing Address	Update	Change Request	IHC Health Services Inc. DBA: Heber Valley Hospital 1485 South Hwy 40 Heber City, UT 84032	IHC Health Services Inc. DBA: Heber Valley Hospital 454 E Medical Way Heber City, UT 84032	3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1005879 (AK)		3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	023789 (AZ)		3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	157331105 (AR)		3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95432498 (CO)		3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	94285405731 (NE)		3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3116907 (OH)		3/4/2021 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q022852 (TN)		3/4/2021 2:22 PM
Addresses	Shipping Address	Delete	Recertification	Heber Valley Hospital Renal Dyalysis 380 East 1500 South STE 101 Heber City, UT 84032		8/28/2020 8:18 AM
Medicaid Billing	NPI: State	Update	Recertification		UT	8/28/2020 8:18 AM
Medicaid Billing	NPI: State	Update	Recertification		UT	8/28/2020 8:18 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 6:10:28 PM	8/28/2020 8:18:01 AM	8/28/2020 8:18 AM
Contacts	Primary Contact	Update	Change Request	Jones, Kevin 340B Program Director Intermountain Healthcare 8012841023	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	5/14/2020 10:56 AM
Details	Entity Name	Update	Change Request	Heber Valley Hospital	IHC Health Services Inc. DBA: Heber Valley Hospital	1/8/2020 11:12 AM
Addresses	Billing Address	Update	Change Request	Heber Valley Hospital 1485 South Hwy 40 Heber City, UT 84032	IHC Health Services Inc. DBA: Heber Valley Hospital 1485 South Hwy 40 Heber City, UT 84032	12/27/2019 11:04 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	870269232341 (UT)		12/27/2019 11:04 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	108778901 (WY)		12/27/2019 11:04 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 4:30:04 PM	8/29/2019 6:10:28 PM	8/29/2019 6:10 PM
Contacts	Authorizing Official	Update	Change Request	Empey, Nathan Director of Finance Intermountain Healthcare 8013577049	Ferry, Jennilyn Finance Director Heber Valley Hospital 4356586709	8/29/2019 11:14 AM
Contacts	Authorizing Official	Update	Profile Change Request	Empey, Nathan Director of Finance Intermountain Healthcare 4356586707	Empey, Nathan Director of Finance Intermountain Healthcare 8013577049	8/14/2019 3:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316055205	8/28/2018 11:10 AM
Contacts	Primary Contact	Update	Recertification	Marsing, Chad Director of Pharmacy intermountain Healthcare 4356574440	Jones, Kevin 340B Program Director Intermountain Healthcare 8012841023	8/23/2018 4:30 PM
Details	Last Recertification Date	Update	Recertification	11/14/2017 5:40:18 PM	8/23/2018 4:30:04 PM	8/23/2018 4:30 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/14/2017 5:40:18 PM	11/14/2017 5:40 PM
Contacts	Primary Contact	Update		Marsing, Chad Director of Pharmacy 4356574440	Marsing, Chad Director of Pharmacy intermountain Healthcare 4356574440	11/3/2017 6:13 PM
Contacts	Authorizing Official	Update		Empey, Nathan Director of Finance 4356586707	Empey, Nathan Director of Finance Intermountain Healthcare 4356586707	10/13/2017 1:24 PM
Contacts	Authorizing Official	Insert			Empey, Nathan Director of Finance 4356586707	7/14/2017 9:19 AM
Contacts	Primary Contact	Insert			Marsing, Chad Director of Pharmacy 4356574440	4/27/2017 8:35 AM
Addresses	Main Address	Insert			380 East 1500 South STE 101 Heber City, UT 84032	4/27/2017 8:34 AM
Addresses	Billing Address	Insert			Heber Valley Hospital 1485 South Hwy 40 Heber City, UT 84032	4/27/2017 8:34 AM
Addresses	Shipping Address	Insert			Heber Valley Hospital 1485 South Hwy 40 Heber City, UT 84032	4/27/2017 8:34 AM
Addresses	Shipping Address	Insert			Heber Valley Hospital Renal Dyalysis 380 East 1500 South STE 101 Heber City, UT 84032	4/27/2017 8:34 AM
Contacts	Signed By	Insert			Weston-Nielson, Lori Director of Finance 4356586707	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			1005879	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			AK	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			023789	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			AZ	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			157331105	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			AR	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			95432498	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			CO	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			94285405731	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			NE	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			3116907	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			OH	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			Q022852	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			TN	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: Number	Insert			108778901	4/27/2017 8:34 AM
Medicaid Billing	Medicaid: State	Insert			WY	4/27/2017 8:34 AM
Details	Entity Name	Update		HEBER VALLEY MEDICAL CENTER	Heber Valley Hospital	12/2/2016 9:37 AM
Details	Last Recertification Date	Update			8/12/2016 12:00:00 AM	8/12/2016 5:37 PM
Dates	Participating Approval Date	Update			7/16/2015 12:00:00 AM	7/16/2015 2:21 PM
Details	State	Update		Pending	Active	7/16/2015 2:21 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/16/2015 2:21 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53738	CAH461307-01	7/15/2015 12:47 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53738	7/15/2015 7:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/15/2015 7:39 AM
Medicaid Billing	Medicaid: Number	Insert			870269232341	7/15/2015 7:39 AM
Medicaid Billing	Medicaid: State	Insert			UT	7/15/2015 7:39 AM
Medicaid Billing	NPI: Number	Insert			1770962771	7/15/2015 7:39 AM
Details	Last Recertification Date	Insert				7/15/2015 7:39 AM
Details	Grant Number	Insert				7/15/2015 7:39 AM
Details	340B ID	Insert				7/15/2015 7:39 AM
Details	Is Authorizing Official EHB Data	Insert				7/15/2015 7:39 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2015 7:39 AM
Details	Medicare Provider Number	Insert			461307	7/15/2015 7:39 AM
Details	Entity Name	Insert			HEBER VALLEY MEDICAL CENTER	7/15/2015 7:39 AM
Details	Program Code	Insert			CAH	7/15/2015 7:39 AM
Details	Entity Subname	Insert			Renal Dialysis	7/15/2015 7:39 AM
Dates	Participating Approval Date	Insert				7/15/2015 7:39 AM
Details	State	Insert			Pending	7/15/2015 7:39 AM
Dates	Registration Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 7:39 AM
Dates	Signed By Date	Insert			7/15/2015 12:00:00 AM	7/15/2015 7:39 AM
Dates	Start Date	Insert				7/15/2015 7:39 AM
Terminations	Termination Comments	Insert				7/15/2015 7:39 AM
Terminations	Termination Date	Insert				7/15/2015 7:39 AM
Terminations	Termination Effective Date	Insert				7/15/2015 7:39 AM
Terminations	Termination Reason	Insert				7/15/2015 7:39 AM