Contract Pharmacy Details

CITY MARKET STORE
DSH460009 University of Utah

Covered Entity Details

Entity Name

University of Utah

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH460009

Entity Address

50 North Medical Drive
Salt Lake City, UT 84132

Medicare Provider Number

460009

Participating Start Date

7/1/1996

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

CITY MARKET STORE

Pharmacy Address

PHARMACY DEPT
425 SOUTH MAIN
MOAB, UT 84532

Pharmacy Comments

Contract Details

Approval Date

7/13/2020

Contract Begin Date

8/28/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Gordon Crabtree, CEO
(801) 587-3572

Contract Pharmacy Representative

Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875

Signed By Date

7/13/2020

340B Drug Pricing Program Database