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SMITH'S PHARMACY #475
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
SMITH'S PHARMACY #475
Pharmacy Address
3215 S. VALLEY ST,
SALT LAKE CITY, UT 84109
Pharmacy Comments
Contract Details
Approval Date
4/13/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/28/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Craig Mills, Chief Financial Officer
(801) 662-6277
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/13/2019
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