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PED463301-07 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
Spina Bifida Clinic 434
Type
Children's Hospital
Rural
No
340B ID
PED463301-07
Medicare Provider Number
463301
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/14/2014
Participating Start Date
4/1/2014
Participating Approval Date
3/10/2014
Last Recertification Date
11/14/2017
Termination Date
Termination Reason
4/1/2018
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Primary Children's Hospital
Sidney Norton, Finance AVP - Pediatrics
(801) 662-6277
Primary Contact
Intermountain Healthcare
Kevin Jones, 340B Program Director
(801) 284-1023
Addresses
Street Address
81 North Mario Capecchi Drive
Salt Lake City, UT 84113
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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