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RRC460006-00 LDS HOSPITAL (Terminated)
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Main Details
Name
LDS HOSPITAL
Subdivision Name
Type
Rural Referral Center
Rural
No
340B ID
RRC460006-00
Medicare Provider Number
460006
Additional Details
Current Program Status
Terminated
Registration Date
12/23/2021
Participating Start Date
1/3/2022
Participating Approval Date
1/3/2022
Last Recertification Date
8/25/2022
Termination Date
Termination Reason
5/15/2023
Change of hospital entity type
Contacts
Authorizing Official
Intermountain Healthcare
Mike DeMotte, Finance Director
(801) 408-2087
Primary Contact
Intermountain Healthcare
Charles B. Stubbs, 340B Pharmacist
(801) 284-1113
Addresses
Street Address
8TH AVENUE AND C STREET.
SALT LAKE CITY, UT 84143
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participated starting 10/20/2021, terminated 10/27/2021. Reinstated 1/3/2022.
01/03/2022
April 2025
April 2025
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