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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/12/2022
Contract Begin Date
4/14/2022
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/12/2022
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