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UTAH CVS PHARMACY, L.L.C.
RRC460006-00 LDS HOSPITAL
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Covered Entity Details
Entity Name
LDS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC460006-00
Entity Address
8TH AVENUE AND C STREET.
SALT LAKE CITY, UT 84143
Medicare Provider Number
460006
Participating Start Date
1/3/2022
Last Recertification Date
8/25/2022
Entity Termination Date
5/15/2023
Pharmacy Details
Pharmacy Name
UTAH CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10230
1273 N. UNIVERSITY AVE.
PROVO, UT 84604
Pharmacy Comments
Contract Details
Approval Date
4/5/2022
Contract Begin Date
4/11/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/15/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mike DeMotte, Finance Director
(801) 408-2087
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/5/2022
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