Provider Demographics
NPI:1508119918
Name:IHC HEALTH SERVICES INC
Entity Type:Organization
Organization Name:IHC HEALTH SERVICES INC
Other - Org Name:INTERMOUNTAIN HOME DELIVERY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL SYSTEMS
Authorized Official - Prefix:
Authorized Official - First Name:NANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-284-1005
Mailing Address - Street 1:PO BOX 30013
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0013
Mailing Address - Country:US
Mailing Address - Phone:855-779-3960
Mailing Address - Fax:
Practice Address - Street 1:7268 S BINGHAM JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4860
Practice Address - Country:US
Practice Address - Phone:855-779-3960
Practice Address - Fax:801-442-4179
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IHC HEALTH SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336S0011X
UT8858671-17033336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1508119918Medicaid
2137364OtherPK
ID1508119918Medicaid