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FRESH MARKET PHARMACY #2312
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
FRESH MARKET PHARMACY #2312
Pharmacy Address
PHARMACY
560 W CENTER
PROVO, UT 84601-4276
Pharmacy Comments
Contract Details
Approval Date
2/21/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/26/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rod Lisonbee, CFO
(801) 357-7212
Contract Pharmacy Representative
Shawna Hanson, Director of Pharmacy
(801) 978-8309
Signed By Date
1/11/2013
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