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WALMART PHARMACY 10-4700
CAH461300-00 IHC Health Services, INC. DBA: INTERMOUNTAIN HEALTH DELTA COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
IHC Health Services, INC. DBA: INTERMOUNTAIN HEALTH DELTA COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH461300-00
Entity Address
126 S WHITE SAGE AVE
DELTA, UT 84624
Medicare Provider Number
461300
Participating Start Date
10/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4700
Pharmacy Address
1707 WEST STATE STREET
PLEASANT GROVE, UT 84062
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/26/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lenny Lyons, Administrator--Delta Community Medical Center
(435) 864-1510
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2019
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