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UTAH CVS PHARMACY, L.L.C.
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
UTAH CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10578
11506 S 4000 W
SOUTH JORDAN, UT 84009
Pharmacy Comments
Contract Details
Approval Date
4/7/2022
Contract Begin Date
4/12/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sidney Norton, Finance AVP - Pediatrics
(801) 662-6277
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/7/2022
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