340B Drug Pricing Program Database
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PED463301-14 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
Primary Children's Hospital Craniofacial/Cleft Palate Clinic - Cleft Palate Clinic
Type
Children's Hospital
Rural
No
340B ID
PED463301-14
Medicare Provider Number
463301
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/15/2020
Participating Start Date
4/1/2020
Participating Approval Date
2/6/2020
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
81 North Mario Capecchi Dr.
Salt Lake City, UT 84113
Billing Address
Primary Children's Hospital
100 North Mario Capecchi Dr.
Salt Lake City, UT 84113
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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