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DAVIS FOOD AND DRUG # 1
SCH460019-00 Uintah Basin Medical Center
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Covered Entity Details
Entity Name
Uintah Basin Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH460019-00
Entity Address
250 West 300 North
Roosevelt, UT 84066
Medicare Provider Number
460019
Participating Start Date
7/1/2012
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
DAVIS FOOD AND DRUG # 1
Pharmacy Address
575 W MAIN ST
VERNAL, UT 84078-2405
Pharmacy Comments
Contract Details
Approval Date
4/9/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent Hales, CFO
(435) 722-6164
Contract Pharmacy Representative
Davis Food and Drug
Mike Sorenson, Pharmacist
(435) 789-2001
Signed By Date
4/9/2024
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