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WAL-MART PHARMACY 10-1440
PED463301-00 IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL
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Covered Entity Details
Entity Name
IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL
Subdivision Name
Type
Children's Hospital
340B ID
PED463301-00
Entity Address
100 NORTH MARIO CAPECCHI DRIVE
SALT LAKE CITY, UT 84113
Medicare Provider Number
463301
Participating Start Date
1/1/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1440
Pharmacy Address
99 WEST 1280 NORTH
TOOELE, UT 84074
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
8/31/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Craig Mills, Chief Financial Officer
(801) 662-6277
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2019
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