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PED463301-02 IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL (Active)
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Main Details
Name
IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL
Subdivision Name
Diabetes Clinic
Type
Children's Hospital
Rural
No
340B ID
PED463301-02
Medicare Provider Number
463301
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
2/14/2020
Participating Start Date
4/1/2020
Participating Approval Date
2/20/2020
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
81 North Mario Cappechi Drive
Salt Lake City, UT 84113
Billing Address
Primary Children's Hospital
100 North Mario Cappechi Drive
Salt Lake City, UT 84113
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 1/1/2014m terminated 4/1/2018. Reinstated 4/1/2020.
02/20/2020
May 2025
May 2025
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