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OPTUM INFUSION SERVICES 500, INC.
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
OPTUM INFUSION SERVICES 500, INC.
Pharmacy Address
4900 RIVERGRADE RD STE E120
IRWINDALE, CA 91706-1419
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
1/19/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/2/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Sidney Norton, Finance AVP - Pediatrics
(801) 662-6277
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2022
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