Provider Demographics
NPI:1508973215
Name:IHC HEALTH SERVICES INC
Entity Type:Organization
Organization Name:IHC HEALTH SERVICES INC
Other - Org Name:ALTA VIEW HOSPITAL OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OUTPATIENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-442-3903
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:
Mailing Address - Fax:
Practice Address - Street 1:9660 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3762
Practice Address - Country:US
Practice Address - Phone:801-501-2741
Practice Address - Fax:801-501-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
UT542044617033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854058189Medicaid
4605234OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4605234OtherOTHER ID NUMBER