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CYSTIC FIBROSIS SERVICES, LLC
DSH460004 IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460004
Entity Address
4401 HARRISON BLVD
OGDEN, UT 84403
Medicare Provider Number
460004
Participating Start Date
6/15/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/5/2020
Contract Begin Date
6/15/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/15/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Trever Porter, Finance Dir-MK
(801) 387-3767
Contract Pharmacy Representative
Intermountain Healthcare
Sabrina Cole, Executive Operations Director, System Pharmacy Services
(801) 284-1002
Signed By Date
5/29/2020
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