340B Drug Pricing Program Database
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PED463301-04 IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL (Terminated)
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Main Details
Name
IHC HEALTH SERVICES INC. DBA PRIMARY CHILDREN'S HOSPITAL
Subdivision Name
Child Residential and Day
Type
Children's Hospital
Rural
No
340B ID
PED463301-04
Medicare Provider Number
463301
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/13/2014
Participating Start Date
4/1/2014
Participating Approval Date
3/10/2014
Last Recertification Date
8/30/2021
Termination Date
Termination Reason
1/1/2022
Business decision by the Covered Entity
Contacts
Authorizing Official
Primary Children's Hospital
Sidney Norton, Finance AVP - Pediatrics
(801) 662-6277
Primary Contact
Intermountain Healthcare
Charles B. Stubbs, 340B Pharmacist
(801) 284-1113
Addresses
Street Address
5770 South 1500 West Building C
Salt Lake City, UT 84123
Billing Address
Primary Children's Hospital
100 North Mario Capecchi Drive
Salt Lake City, UT 84113
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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