Covered Entity Details

RRC460010-10 IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER (Active) - information as of 4/25/2025 8:32:50 PM

Main Details

Name

IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER

Subdivision Name

Same Day Surgery - ECCLES OUTPATIENT CARE CENTER - Same Day Surgery

Type

Rural Referral Center

Rural

Yes

340B ID

RRC460010-10

Medicare Provider Number

460010

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

6/3/2022

Participating Start Date

6/8/2022

Participating Approval Date

6/8/2022

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Intermountain Healthcare
Nathan Empey, Director of Finance
(801) 357-7049

Primary Contact

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

Addresses

Street Address

5169 South Cottonwood Street, Suite Level 2
Murray, UT 84107

Billing Address

INTERMOUNTAIN MEDICAL CENTER
5121 S COTTONWOOD ST
MURRAY, UT 84107

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		1043220650

Shipping Addresses

Shipping Address 1

INTERMOUNTAIN MEDICAL CENTER
5121 S COTTONWOOD ST
MURRAY, UT 84107

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
RRC460010-01	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Medical Center Dialysis Services - Dialysis Intermountain Med Ctr	74 W Vine St	MURRAY	UT	Active
RRC460010-02	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN MEDICAL CENTER	Intermountain Medical Center Infusion Services - Infusion Center	5131 South Cottonwood Street, Suite 300	MURRAY	UT	Terminated
RRC460010-03	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Medical Center – Infectious Disease Clinic - Infectious Disease	5171 South Cottonwood Street, Suite 350	Murray	UT	Active
RRC460010-04	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Adult Congenital Heart Disease Clinic - Adult Congenital Heart Disease	5171 South Cottonwood Street; Level 5	MURRAY	UT	Active
RRC460010-05	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Post Anesthesia Care Unit - ECCLES OUTPATIENT CARE CENTER - Post Anesthesia Care Unit-PACU	5169 South Cottonwood Street, Suite Level 2	MURRAY	UT	Active
RRC460010-06	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Transplant Center - Liver Transplant	5171 South Cottonwood Street Suite 210	Murray	UT	Active
RRC460010-07	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Transplant Center - Kidney Transplant	5171 South Cottonwood Street Suite 210	MURRAY	UT	Active
RRC460010-08	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	IMC Tooele Valley Dialysis - Dialysis Tooele	2356 N 400 E B102	Tooele	UT	Active
RRC460010-09	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Endoscopy - ECCLES OUTPATIENT CARE CENTER - Endoscopy Lab	5169 South Cottonwood Street, Suite Level 2	MURRAY	UT	Active
RRC460010-10	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Same Day Surgery - ECCLES OUTPATIENT CARE CENTER - Same Day Surgery	5169 South Cottonwood Street, Suite Level 2	Murray	UT	Active
RRC460010-11	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Utah Dialysis - Dialysis	1000 Main St #105	SALT LAKE CITY	UT	Active
RRC460010-12	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Operating Room - ECCLES OUTPATIENT CARE CENTER - Operating Rooms	5169 South Cottonwood Street, Suite Level 2	Murray	UT	Active
RRC460010-13	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Radiation Therapy Cancer Center - Radiation Center	5131 South Cottonwood Street, Suite 100	MURRAY	UT	Active
RRC460010-14	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Heart Failure Clinic - Heart Failure Preventn -Trtmnt	5171 South Cottonwood Street; Level 5	MURRAY	UT	Active
RRC460010-15	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Intermountain Cardiac Care Clinic - Cardiac Care Clinic	5171 South Cottonwood Street; Level 5	MURRAY	UT	Active
RRC460010-16	Child	RRC	INTERMOUNTAIN MEDICAL CENTER	Clinical Anticoagulation Services - Clinical Anticoagulation	5169 South Cottonwood Street, Suite 500	MURRAY	UT	Terminated
RRC460010-17	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Radiology - ECCLES OUTPATIENT CARE CENTER - Nuclear Medicine	5169 South Cottonwood Street, Level 2	Murray	UT	Active
RRC460010-18	Child	RRC	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	Radioisotope - Positron Emission Tomography - Positron Emission Tomography	5169 South Cottonwood Street, Level 2	Murray	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	IHC Health Services Inc. dba INTERMOUNTAIN MEDICAL CENTER	IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER	2/6/2025 10:51 AM
Details	Entity Name	Update	Change Request	INTERMOUNTAIN MEDICAL CENTER	IHC Health Services Inc. dba INTERMOUNTAIN MEDICAL CENTER	9/26/2024 9:39 AM
Details	Last Recertification Date	Update	Recertification	8/14/2023 10:49:44 AM	8/21/2024 12:27:29 PM	8/21/2024 12:27 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	5/3/2024 5:58 AM
Contacts	Authorizing Official	Update	Change Request	Stephens, Royce Finance Director Intermountain Medical Center 8015077948	Empey, Nathan Director of Finance Intermountain Healthcare 8013577049	11/3/2023 9:29 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 12:22:29 PM	8/14/2023 10:49:44 AM	8/14/2023 10:49 AM
Details	Last Recertification Date	Update	Recertification		8/25/2022 12:22:29 PM	8/25/2022 12:22 PM
Details	State	Update	OPA Edit	Approved	Active	6/8/2022 2:14 PM
Dates	Start Date	Update	OPA Edit	7/1/2022 12:00:00 AM	6/8/2022 12:00:00 AM	6/8/2022 2:14 PM
Addresses	Main Address	Insert	New Registration		5169 South Cottonwood Street, Suite Level 2 Murray, UT 84107	6/8/2022 2:03 PM
Addresses	Billing Address	Insert	New Registration		INTERMOUNTAIN MEDICAL CENTER 5121 S COTTONWOOD ST MURRAY, UT 84107	6/8/2022 2:03 PM
Contacts	Signed By	Insert	New Registration		Stephens, Royce Finance Director Intermountain Medical Center 8015077948	6/8/2022 2:03 PM
Details	340B ID	Update	New Registration		RRC460010-10	6/8/2022 2:03 PM
Details	Entity Subname	Update	New Registration	Same Day Surgery - ECCLES OUTPATIENT CARE CENTER	Same Day Surgery - ECCLES OUTPATIENT CARE CENTER - Same Day Surgery	6/8/2022 2:03 PM
Dates	Participating Approval Date	Update	New Registration		6/8/2022 2:03:27 PM	6/8/2022 2:03 PM
Details	State	Update	New Registration	Pending	Approved	6/8/2022 2:03 PM
Dates	Signed By Date	Update	New Registration		6/6/2022 3:22:05 PM	6/8/2022 2:03 PM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	6/8/2022 2:03 PM
Addresses	Main Address	Insert	New Registration		5169 South Cottonwood Street, Suite Level 2 MURRAY Murray, UT 84107	6/3/2022 4:15 PM
Addresses	Billing Address	Insert	New Registration		INTERMOUNTAIN MEDICAL CENTER 5121 S COTTONWOOD ST MURRAY, UT 84107	6/3/2022 4:15 PM
Addresses	Shipping Address	Insert	New Registration		INTERMOUNTAIN MEDICAL CENTER 5121 S COTTONWOOD ST MURRAY, UT 84107	6/3/2022 4:15 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1043220650	6/3/2022 4:15 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	6/3/2022 4:15 PM
Contacts	Primary Contact	Insert	New Registration		Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	6/3/2022 4:15 PM
Contacts	Authorizing Official	Insert	New Registration		Stephens, Royce Finance Director Intermountain Medical Center 8015077948	6/3/2022 4:15 PM
Details	Assistance Received From Date	Insert	New Registration			6/3/2022 4:15 PM
Details	Assistance Received To Date	Insert	New Registration			6/3/2022 4:15 PM
Details	Last Recertification Date	Insert	New Registration			6/3/2022 4:15 PM
Details	Grant Number	Insert	New Registration			6/3/2022 4:15 PM
Details	340B ID	Insert	New Registration			6/3/2022 4:15 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			6/3/2022 4:15 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			6/3/2022 4:15 PM
Details	Medicare Provider Number	Insert	New Registration		460010	6/3/2022 4:15 PM
Details	Entity Name	Insert	New Registration		INTERMOUNTAIN MEDICAL CENTER	6/3/2022 4:15 PM
Details	NOFO Number	Insert	New Registration			6/3/2022 4:15 PM
Details	Program Code	Insert	New Registration		RRC	6/3/2022 4:15 PM
Details	Entity Subname	Insert	New Registration		Same Day Surgery - ECCLES OUTPATIENT CARE CENTER	6/3/2022 4:15 PM
Dates	Participating Approval Date	Insert	New Registration			6/3/2022 4:15 PM
Details	State	Insert	New Registration		Pending	6/3/2022 4:15 PM
Dates	Registration Date	Insert	New Registration		6/3/2022 4:15:26 PM	6/3/2022 4:15 PM
Dates	Signed By Date	Insert	New Registration			6/3/2022 4:15 PM
Dates	Start Date	Insert	New Registration			6/3/2022 4:15 PM
Terminations	Termination Comments	Insert	New Registration			6/3/2022 4:15 PM
Terminations	Termination Date	Insert	New Registration			6/3/2022 4:15 PM
Terminations	Termination Effective Date	Insert	New Registration			6/3/2022 4:15 PM
Terminations	Termination Reason	Insert	New Registration			6/3/2022 4:15 PM