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CYSTIC FIBROSIS SERVICES, LLC
DSH460006 IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL
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Covered Entity Details
Entity Name
IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH LDS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460006
Entity Address
8TH AVENUE AND C STREET.
SALT LAKE CITY, UT 84143
Medicare Provider Number
460006
Participating Start Date
5/15/2023
Last Recertification Date
8/15/2024
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
5/15/2023
Contract Begin Date
5/15/2023
Carve-In Effective Date
Contract Comments
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
5/4/2023
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