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UTAH CVS PHARMACY, L.L.C.
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
UTAH CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10234
4240 HARRISON BLVD.
OGDEN, UT 84403
Pharmacy Comments
Contract Details
Approval Date
7/13/2021
Contract Begin Date
8/3/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/12/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Trever Porter, Finance Dir-MK
(801) 387-3767
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/13/2021
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