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CYSTIC FIBROSIS SERVICES, LLC
DSH460004 IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460004
Entity Address
4401 HARRISON BLVD
OGDEN, UT 84403
Medicare Provider Number
460004
Participating Start Date
6/15/2020
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
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kerry Gillespie, CFO-Specialty Based Care
(801) 442-2459
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/12/2018
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