Provider Demographics
NPI:1457556243
Name:IHC HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:IHC HEALTH SERVICES, INC.
Other - Org Name:IMC COMMUNITY 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:801-507-3030
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:BUILDING 2
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-3030
Practice Address - Fax:801-507-3019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IHC HEALTH SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT656481817033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100924OtherPK
MT1457556243Medicaid
WY1457556243Medicaid
UT1457556243Medicaid
ID807887900Medicaid
0358080018Medicare NSC