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IHC HEALTH SERVICES, INC.
DSH460015 LOGAN REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
LOGAN REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460015
Entity Address
1400 NORTH 500 EAST
LOGAN, UT 84341
Medicare Provider Number
460015
Participating Start Date
7/1/2011
Last Recertification Date
8/22/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
IHC HEALTH SERVICES, INC.
Pharmacy Address
DBA: INTERMOUNTAIN SPECIALTY PHARMACY
4393 RIVERBOAT RD SUITE 101
TAYLORSVILLE, UT 84123
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Justin Wiser, Finance Director
(435) 716-5331
Contract Pharmacy Representative
Intermountain Healthcare
Buck Stanford, Pharmacy Operations Dir-System
(801) 284-1005
Signed By Date
10/15/2018
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