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WAL-MART PHARMACY 10-1768
DSH460001 IHC Health Services, Inc. DBA: INTERMOUNTAIN HEALTH UTAH VALLEY HOSPITAL
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Covered Entity Details
Entity Name
IHC Health Services, Inc. DBA: INTERMOUNTAIN HEALTH UTAH VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460001
Entity Address
1034 NORTH 500 WEST
PROVO, UT 84604
Medicare Provider Number
460001
Participating Start Date
10/1/2006
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1768
Pharmacy Address
1355 SOUTH SANDHILL RD
OREM, UT 84058
Pharmacy Comments
Contract Details
Approval Date
11/14/2012
Contract Begin Date
11/14/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/7/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rod Lisonbee, CFO
(801) 357-7212
Contract Pharmacy Representative
Walmart
Craig Smith, Senior Manager Health & Wellness Payer Relations
(479) 903-5739
Signed By Date
9/27/2012
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