Covered Entity Details

DSH460006B IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL (Active) - information as of 6/14/2025 10:10:08 AM

Main Details

Name

IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL

Subdivision Name

LDS HOSPITAL VOICE AND SWALLOWING CENTER - SPEECH - OUTPATIENT

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH460006B

Medicare Provider Number

460006

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/3/2023

Participating Start Date

5/15/2023

Participating Approval Date

5/15/2023

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Intermountain Healthcare
Mike DeMotte, Finance Director
(801) 408-2087

Primary Contact

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

Addresses

Street Address

440 D STREET E #202
SALT LAKE CITY, UT 84103

Billing Address

LDS HOSPITAL
8TH AVENUE AND C STREET
SALT LAKE CITY, UT 84103

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		1528078581

Shipping Addresses

Shipping Address 1

LDS HOSPITAL
8TH AVENUE AND C STREET
SALT LAKE CITY, UT 84103

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
DSH460006A	Child	DSH	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL	LDS HOSPITAL OUTPATIENT PULMONARY CLINIC - PULMONARY CLINIC	324 10th Ave #170	SALT LAKE CITY	UT	Active
DSH460006B	Child	DSH	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL	LDS HOSPITAL VOICE AND SWALLOWING CENTER - SPEECH - OUTPATIENT	440 D STREET E #202	SALT LAKE CITY	UT	Active
DSH460006C	Child	DSH	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL	Infusion Center - Murray Campus	5131 South Cottonwood Street, Suite 300	Murray	UT	Active
DSH460006D	Child	DSH	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL	Infusion Clinic - Alta View Campus - Bone Marrow Transplant - Infusion	9450 S 1300 E Suite 450	Sandy	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	IHC Health Services Inc. dba LDS HOSPITAL	IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL	1/30/2025 9:44 AM
Details	Entity Name	Update	Change Request	LDS HOSPITAL	IHC Health Services Inc. dba LDS HOSPITAL	9/27/2024 7:02 AM
Details	Last Recertification Date	Update	Recertification	8/16/2023 12:08:38 PM	8/15/2024 10:49:34 AM	8/15/2024 10:49 AM
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 3:20 PM
Details	Last Recertification Date	Update	Recertification		8/16/2023 12:08:38 PM	8/16/2023 12:08 PM
Details	State	Update	OPA Edit	Approved	Active	5/15/2023 12:27 PM
Dates	Start Date	Update	OPA Edit	7/1/2023 12:00:00 AM	5/15/2023 12:00:00 AM	5/15/2023 12:27 PM
Contacts	Signed By	Insert	New Registration		DeMotte, Mike Finance Director Intermountain Healthcare 8014082087	5/15/2023 12:26 PM
Details	340B ID	Update	New Registration		DSH460006B	5/15/2023 12:26 PM
Details	Entity Subname	Update	New Registration	LDS HOSPITAL VOICE AND SWALLOWING CENTER	LDS HOSPITAL VOICE AND SWALLOWING CENTER - SPEECH - OUTPATIENT	5/15/2023 12:26 PM
Dates	Participating Approval Date	Update	New Registration		5/15/2023 12:26:12 PM	5/15/2023 12:26 PM
Details	State	Update	New Registration	Pending	Approved	5/15/2023 12:26 PM
Dates	Signed By Date	Update	New Registration		5/4/2023 5:16:42 PM	5/15/2023 12:26 PM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/15/2023 12:26 PM
Addresses	Main Address	Insert	New Registration		440 D STREET E #202 SALT LAKE CITY, UT 84103	5/3/2023 2:11 PM
Addresses	Billing Address	Insert	New Registration		LDS HOSPITAL 8TH AVENUE AND C STREET SALT LAKE CITY, UT 84103	5/3/2023 2:11 PM
Addresses	Shipping Address	Insert	New Registration		LDS HOSPITAL 8TH AVENUE AND C STREET SALT LAKE CITY, UT 84103	5/3/2023 2:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1528078581	5/3/2023 2:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	5/3/2023 2:11 PM
Contacts	Primary Contact	Insert	New Registration		Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	5/3/2023 2:11 PM
Contacts	Authorizing Official	Insert	New Registration		DeMotte, Mike Finance Director Intermountain Healthcare 8014082087	5/3/2023 2:11 PM
Details	Assistance Received From Date	Insert	New Registration			5/3/2023 2:11 PM
Details	Assistance Received To Date	Insert	New Registration			5/3/2023 2:11 PM
Details	Last Recertification Date	Insert	New Registration			5/3/2023 2:11 PM
Details	Grant Number	Insert	New Registration			5/3/2023 2:11 PM
Details	340B ID	Insert	New Registration			5/3/2023 2:11 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			5/3/2023 2:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			5/3/2023 2:11 PM
Details	Medicare Provider Number	Insert	New Registration		460006	5/3/2023 2:11 PM
Details	Entity Name	Insert	New Registration		LDS HOSPITAL	5/3/2023 2:11 PM
Details	NOFO Number	Insert	New Registration			5/3/2023 2:11 PM
Details	Program Code	Insert	New Registration		DSH	5/3/2023 2:11 PM
Details	Entity Subname	Insert	New Registration		LDS HOSPITAL VOICE AND SWALLOWING CENTER	5/3/2023 2:11 PM
Dates	Participating Approval Date	Insert	New Registration			5/3/2023 2:11 PM
Details	State	Insert	New Registration		Pending	5/3/2023 2:11 PM
Dates	Registration Date	Insert	New Registration		5/3/2023 2:11:39 PM	5/3/2023 2:11 PM
Dates	Signed By Date	Insert	New Registration			5/3/2023 2:11 PM
Dates	Start Date	Insert	New Registration			5/3/2023 2:11 PM
Terminations	Termination Comments	Insert	New Registration			5/3/2023 2:11 PM
Terminations	Termination Date	Insert	New Registration			5/3/2023 2:11 PM
Terminations	Termination Effective Date	Insert	New Registration			5/3/2023 2:11 PM
Terminations	Termination Reason	Insert	New Registration			5/3/2023 2:11 PM