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WAL-MART PHARMACY 10-5168
CAH461333-00 IHC Health Services Inc. DBA Intermountain Health Garfield Memorial Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health Garfield Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH461333-00
Entity Address
200 North 400 East
Panguitch, UT 84759
Medicare Provider Number
461333
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5168
Pharmacy Address
10 EAST 1300 SOUTH
RICHFIELD, UT 84701
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/11/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alberto Vasquez, Administrator
(435) 676-1261
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2019
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