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CYSTIC FIBROSIS SERVICES, LLC
PED463301-00 IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL
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Covered Entity Details
Entity Name
IHC HEALTH SERVICES, INC. INTERMOUNTAIN HEALTH PRIMARY CHILDREN'S HOSPITAL
Subdivision Name
Type
Children's Hospital
340B ID
PED463301-00
Entity Address
100 NORTH MARIO CAPECCHI DRIVE
SALT LAKE CITY, UT 84113
Medicare Provider Number
463301
Participating Start Date
1/1/2010
Last Recertification Date
8/19/2024
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
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Craig Mills, Chief Financial Officer
(801) 662-6277
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/14/2017
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