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RRC460010-16 INTERMOUNTAIN MEDICAL CENTER (Terminated)
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Main Details
Name
INTERMOUNTAIN MEDICAL CENTER
Subdivision Name
Clinical Anticoagulation Services - Clinical Anticoagulation
Type
Rural Referral Center
Rural
Yes
340B ID
RRC460010-16
Medicare Provider Number
460010
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
6/6/2022
Participating Start Date
6/14/2022
Participating Approval Date
6/14/2022
Last Recertification Date
8/25/2022
Termination Date
Termination Reason
10/1/2023
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Intermountain Medical Center
Royce Stephens, Finance Director
(801) 507-7948
Primary Contact
Intermountain Healthcare
Charles B. Stubbs, 340B Pharmacist
(801) 284-1113
Addresses
Street Address
5169 South Cottonwood Street, Suite 500
MURRAY, UT 84107
Billing Address
INTERMOUNTAIN MEDICAL CENTER
5121 S COTTONWOOD ST
MURRAY, UT 84107
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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