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SMITHS FOOD & DRUG CTRS
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
SMITHS FOOD & DRUG CTRS
Pharmacy Address
DBA SMITH'S FOOD & DRUG #136
350 NORTH FREEDOM BOULEVARD
PROVO, UT 84601
Pharmacy Comments
Contract Details
Approval Date
11/20/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rod Lisonbee, CFO
(801) 357-7212
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/9/2012
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