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MAXOR SPECIALTY PHARMACY
DSH460009 University of Utah
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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
MAXOR SPECIALTY PHARMACY
Pharmacy Address
150 CLEVELAND RD
SUITE B
BOGART, GA 30622-1701
Pharmacy Comments
Contract Details
Approval Date
10/13/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/2/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charlton Gordon Park, Chief Financial Officer
(801) 585-1325
Contract Pharmacy Representative
Maxor
Jessie Heaton, Pharmacist-in-charge
(800) 658-6046
Signed By Date
10/13/2021
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