Covered Entity Details

DSH060023 St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital (Active) - information as of 6/14/2025 10:06:53 AM

Main Details

Name

St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH060023

Medicare Provider Number

060023

Additional Details

Current Program Status

Active

Registration Date

7/9/2014

Participating Start Date

10/1/2014

Participating Approval Date

8/29/2014

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Intermountain Healthcare
Vincent Donohue, Finance Director-Central UT Rural
(435) 983-0527

Primary Contact

Intermountain Health
Ben Landry, 340B Pharmacist
(207) 200-5264

Addresses

Street Address

2635 N. 7TH STREET
GRAND JUNCTION, CO 81501

Billing Address

St Mary’s Hospital and Medical Center Inc.
Attn: Accounts Payable
P.O. Box 1010
Lafayette, CO 80026

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CO		1124274436,1699716027,1821647801

Shipping Addresses

Shipping Address 1

St. Mary's Hospital and Medical Center, Inc
2635 N. 7th Street
Grand Junction, CO 81501

Shipping Address 2

St. Mary's Medical Center Cancer Centers of Colorado Pharmacy
750 Wellington Avenue
Grand Junction, CO 81501

Shipping Address 3

INTERMOUNTAIN SCC ACUTE SERVICES PHARMACY
7268 S BINGHAM JUNCTION BLVD
STE A
MIDVALE, UT 84047

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/18/2017	07/01/2017		04/18/2017
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	04/18/2017	07/01/2017	01/15/2018	01/16/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/18/2017	07/01/2017	11/14/2019	11/18/2019
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/18/2017	07/01/2017		04/18/2017
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/12/2023	10/01/2023		10/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/18/2017	07/01/2017	07/11/2023	07/12/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/18/2017	07/01/2017	11/14/2019	11/18/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/18/2017	07/01/2017	11/14/2019	11/18/2019
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/17/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/18/2017	04/01/2017	11/14/2019	11/18/2019
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/18/2017	04/01/2017		01/18/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/18/2017	04/01/2017		01/18/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CITY MARKET PHARMACY	16400 S. TOWNSEND		MONTROSE	CO	81401	09/05/2014	10/01/2014	06/30/2015	11/13/2015
Contract Detail	CITY MARKET PHARMACY #13	135 SOUTH PLUM		FRUITA	CO	81521	09/05/2014	10/01/2014	12/19/2020	01/18/2021
Contract Detail	CITY MARKET PHARMACY #13	135 SOUTH PLUM		FRUITA	CO	81521	07/12/2023	10/01/2023	11/13/2023	11/13/2023
Contract Detail	CITY MARKET PHARMACY #25	569 32 ROAD		GRAND JUNCTION	CO	81504	09/05/2014	10/01/2014	12/19/2020	01/18/2021
Contract Detail	CITY MARKET PHARMACY #25	569 32 ROAD		GRAND JUNCTION	CO	81504	07/12/2023	10/01/2023	11/13/2023	11/13/2023
Contract Detail	CITY MARKET PHARMACY #29	215 SIXTH STREET	PO BOX 928	HOTCHKISS	CO	81419	09/05/2014	10/01/2014	12/19/2020	01/18/2021
Contract Detail	CITY MARKET PHARMACY #3	128 SOUTH TOWNSEND	PO BOX 608	MONTROSE	CO	81401	09/05/2014	10/01/2014	06/30/2015	11/13/2015
Contract Detail	CITY MARKET PHARMACY #401	2770 HWY 50 SOUTH		GRAND JUNCTION	CO	81503	09/05/2014	10/01/2014	12/19/2020	01/18/2021
Contract Detail	CITY MARKET PHARMACY #401	2770 HWY 50 SOUTH		GRAND JUNCTION	CO	81503	07/12/2023	10/01/2023	11/13/2023	11/13/2023
Contract Detail	CITY MARKET PHARMACY #404	PHARMACY DEPARTMENT	122 GUNNISON RIVER DRIVE	DELTA	CO	81416	09/05/2014	10/01/2014	12/19/2020	01/18/2021
Contract Detail	CITY MARKET PHARMACY #444	2600 NORTH 12TH ST		GRAND JUNCTION	CO	81501	10/20/2016	01/01/2017	12/19/2020	01/18/2021
Contract Detail	CITY MARKET PHARMACY #444	2600 NORTH 12TH ST		GRAND JUNCTION	CO	81501	07/12/2023	10/01/2023	11/13/2023	11/13/2023
Contract Detail	CITY MARKET PHARMACY #451	630 24 ROAD		GRAND JUNCTION	CO	81505	09/05/2014	10/01/2014	01/01/2021	04/06/2021
Contract Detail	CITY MARKET PHARMACY #451	630 24 ROAD		GRAND JUNCTION	CO	81505	07/12/2023	10/01/2023		10/01/2023
Contract Detail	CITY MARKET STORE #32	PHARMACY DEPARTMENT	200 ROOD AVENUE	GRAND JUNCTION	CO	81501	09/05/2014	10/01/2014	11/14/2019	11/18/2019
Contract Detail	CITY MARKET STORE #443	PHARMACY DEPARTMENT	1320 RAILROAD AVENUE	RIFLE	CO	81650	01/20/2016	04/01/2016	04/09/2021	04/09/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/21/2021	01/01/2022		01/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	01/20/2016	04/01/2016	08/09/2017	08/09/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	06/28/2017	07/01/2017	11/14/2019	11/18/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	01/20/2016	04/01/2016	04/25/2022	04/27/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	G3320 BEECHER RD		FLINT	MI	48532-3614	01/20/2016	04/01/2016	04/17/2017	04/18/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	1370 BUSCH PKWY		BUFFALO GROVE	IL	60089-4505	01/20/2016	04/01/2016	04/17/2017	04/18/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF FT LAUDER	DIPLOMAT SPECIALTY PHARMACY	15471 SW 12TH ST STE 207	SUNRISE	FL	33326	01/20/2016	04/01/2016	04/17/2017	04/18/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	01/20/2016	04/01/2016	04/17/2017	04/18/2017
Contract Detail	IHC HEALTH SERVICES, INC.	DBA: INTERMOUNTAIN HOME DELIVERY PHARMAC	DBA: INTERMOUNTAIN SPECIALTY PHARMACY 7268 S BINGHAM JUNCTION BLVD STE B1	MIDVALE	UT	84047	10/12/2023	01/01/2024		01/01/2024
Contract Detail	IHC HEALTH SERVICES, INC.	DBA: INTERMOUNTAIN SPECIALTY PHARMACY	4393 RIVERBOAT RD SUITE 101	TAYLORSVILLE	UT	84123	10/12/2023	01/01/2024	05/24/2024	05/24/2024
Contract Detail	INTERMOUNTAIN HEALTH GOOD SAMARITAN HOSP	PHARMACY DEPT	200 EXEMPLA CIR	LAFAYETTE	CO	80026	10/08/2015	01/01/2016	11/14/2019	11/18/2019
Contract Detail	INTERMOUNTAIN HEALTH SAINT JOSEPH HOSPIT	1825 MARION ST		DENVER	CO	80218	09/05/2014	10/01/2014	01/01/2021	04/16/2021
Contract Detail	INTERMOUNTAIN PHARMACY #05	1375 E 19TH AVE	STE 1665	DENVER	CO	80218	01/14/2021	04/01/2021		04/01/2021
Contract Detail	INTERMOUNTAIN PHARMACY #07	200 EXEMPLA CIR STE P1-142		LAFAYETTE	CO	80026	07/16/2018	10/01/2018		07/31/2019
Contract Detail	INTERMOUNTAIN SPECIALTY PHARMACY - DENVE	1830 N FRANKLIN ST	STE 190	DENVER	CO	80218	01/09/2017	04/01/2017		01/09/2017
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/19/2020	01/01/2021	08/16/2021	08/17/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/19/2022	04/20/2022	11/07/2024	11/20/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/19/2020	01/01/2021	11/07/2024	11/20/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/19/2022	07/01/2022	10/27/2023	10/30/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/24/2023	01/25/2023	07/11/2023	07/12/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/18/2017	04/01/2017		01/18/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/21/2021	01/01/2022		01/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/21/2021	01/01/2022		01/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #102	2101 N URSULA STREET UNIT 35	AURORA	CO	80045-7426	02/28/2023	03/06/2023		03/06/2023
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1533	2901 F ROAD	GRAND JUNCTION	CO	81504	09/05/2014	10/01/2014	11/14/2019	11/18/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1131	1329 S. TOWNSEND AVENUE	MONTROSE	CO	81401	09/05/2014	10/01/2014	11/14/2019	11/18/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1863	1550 HIGHWAY 92	DELTA	CO	81416	09/05/2014	10/01/2014	11/14/2019	11/18/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2625	681 HORIZON DRIVE	GRAND JUNCTION	CO	81506	09/05/2014	10/01/2014	11/14/2019	11/18/2019
Contract Detail	THE KROGER CO., KS 113	1220 S. LIPAN STREET		DENVER	CO	80223	04/18/2017	07/01/2017	11/14/2019	11/18/2019
Contract Detail	THE KROGER CO., KS 113	1220 S. LIPAN STREET		DENVER	CO	80223	01/15/2020	04/01/2020	01/01/2021	04/06/2021
Contract Detail	THE KROGER CO., KS 113	1220 S. LIPAN STREET		DENVER	CO	80223	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/16/2019	01/01/2020	01/18/2021	01/18/2021
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/04/2023	01/13/2023	10/03/2023	10/03/2023
Contract Detail	WAL-MART PHARMACY 10-1280	2881 NORTH AVENUE		GRAND JUNCTION	CO	81501	10/16/2019	01/01/2020	01/18/2021	01/18/2021
Contract Detail	WAL-MART PHARMACY 10-1280	2881 NORTH AVENUE		GRAND JUNCTION	CO	81501	01/04/2023	01/13/2023	10/03/2023	10/03/2023
Contract Detail	WAL-MART PHARMACY 10-5099	2545 RIMROCK AVE		GRAND JUNCTION (W)	CO	81505	10/16/2019	01/01/2020	01/18/2021	01/18/2021
Contract Detail	WAL-MART PHARMACY 10-5099	2545 RIMROCK AVE		GRAND JUNCTION (W)	CO	81505	01/04/2023	01/13/2023	10/03/2023	10/03/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/16/2019	01/01/2020	01/18/2021	01/18/2021
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/04/2023	01/13/2023	10/03/2023	10/03/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #11187	316 W. ASPEN AVE.	FRUITA	CO	81521	01/20/2016	04/01/2016		07/31/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06108	572 32 ROAD	CLIFTON	CO	81520-7606	01/20/2016	04/01/2016		07/31/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09493	2351 S TOWNSEND AVE	MONTROSE	CO	81401	01/20/2016	04/01/2016		01/20/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09769	2900 NORTH AVENUE	GRAND JUNCTION	CO	81504-5315	01/20/2016	04/01/2016		01/20/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10307	240 W PARK DRIVE	GRAND JUNCTION	CO	81505-1450	01/20/2016	04/01/2016		07/23/2019
Contract Detail	Walgreens #21397	Walgreens Central Fill #21397	5675 Pecos St. Suite 100	Denver	CO	80221-6655	04/14/2023	07/01/2023		07/01/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/20/2016	04/01/2016	06/21/2021	06/23/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/20/2016	04/01/2016	06/21/2021	06/23/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/20/2016	04/01/2016	06/21/2021	06/23/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/20/2016	04/01/2016	06/21/2021	06/23/2021
Contract Detail	WALMART PHARMACY 10-4491	541 WARRIOR WAY		GRAND JUNCTION	CO	81504	10/16/2019	01/01/2020	01/18/2021	01/18/2021
Contract Detail	WALMART PHARMACY 10-4491	541 WARRIOR WAY		GRAND JUNCTION	CO	81504	01/04/2023	01/13/2023	10/03/2023	10/03/2023
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/04/2023	01/13/2023	10/03/2023	10/03/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH060023A	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	ST MARY'S MEDICAL CENTER CANCER CENTERS OF COLORADO - MEDICAL ONCOLOGY	750 WELLINGTON AVE	GRAND JUNCTION	CO	Active
DSH060023B	Child	DSH	ST. MARY'S HOSPITAL & MEDICAL CENTER, INC.	ST MARYS NEPHROLOGY CLINIC	2635 N. 7TH STREET	GRAND JUNCTION	CO	Terminated
DSH060023C	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	ST. MARY'S PAVILION DIAGNOSTIC RADIOLOGY - PAVILION IMAGING-DIAGNOSTIC RADIOLOGY	750 WELLINGTON AVE	GRAND JUNCTION	CO	Active
DSH060023D	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	ST. MARY'S COUMADIN CLINIC	2686 PATTERSON ROAD	GRAND JUNCTION	CO	Active
DSH060023E	Child	DSH	ST. MARY'S HOSPITAL & MEDICAL CENTER, INC.	ST. MARY'S LIFE CENTER - Occupational Therapy	2686 PATTERSON RD	GRAND JUNCTION	CO	Terminated
DSH060023F	Child	DSH	ST. MARY'S HOSPITAL & MEDICAL CENTER, INC.	ST. MARY'S DIABETES EDUCATION	2686 PATTERSON RD	GRAND JUNCTION	CO	Terminated
DSH060023G	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	Radiation Therapy - Radiation Therapy	750 WELLINGTON AVE	GRAND JUNCTION	CO	Active
DSH060023H	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	St. Mary's Pavilion MRI - Pavilion Imaging-MRI	750 Wellington Ave	Grand Junction	CO	Active
DSH060023J	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	St. Mary's Pavilion Ultrasonography - Pavilion Imaging-Ultrasonography	750 Wellington Ave	Grand Junction	CO	Active
DSH060023K	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	St. Mary's Pavilion CT Scan - Pavilion Imaging-CT Scan	750 Wellington Ave	Grand Junction	CO	Active
DSH060023L	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	St. Mary's Pavilion PET Scan - Pavilion Imaging-PET Scan	750 Wellington Ave	Grand Junction	CO	Active
DSH060023M	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	St. Mary's Pavilion Mammography - Pavilion Imaging-Mammography	750 Wellington Ave	Grand Junction	CO	Active
DSH060023N	Child	DSH	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	St. Mary's Medical Center Cancer Centers of Colorado - Medical Oncology Infusion	750 Wellington Ave.	Grand Junction	CO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Fadden, Sean Vice President Finance Intermountain Health - Peaks Region 3032720416	Donohue, Vincent Finance Director-Central UT Rural Intermountain Healthcare 4359830527	1/23/2025 1:46 PM
Contacts	Authorizing Official	Update	Change Request	Thurow, Ashley VP Finance St. Mary's Medical Center 9702982020	Fadden, Sean Vice President Finance Intermountain Health - Peaks Region 3032720416	9/5/2024 9:07 AM
Details	Last Recertification Date	Update	Recertification	8/24/2023 3:05:12 PM	8/20/2024 1:29:45 PM	8/20/2024 1:29 PM
Contacts	Primary Contact	Update	Change Request	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	Landry, Ben 340B Pharmacist Intermountain Health 2072005264	5/7/2024 7:33 AM
Details	Entity Name	Update	Change Request	ST. MARY'S HOSPITAL & MEDICAL CENTER, INC.	St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital	5/7/2024 7:33 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 7:12:38 AM	8/24/2023 3:05:12 PM	8/24/2023 3:05 PM
Contacts	Authorizing Official	Update	Change Request	Chinn, Terri VP of Finance SCL Health 9702982020	Thurow, Ashley VP Finance St. Mary's Medical Center 9702982020	6/20/2023 1:19 PM
Contacts	Primary Contact	Update	Change Request	Bormann, Rudy E Director of Pharmacy SCL Health 9702982460	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	6/14/2023 7:36 AM
Addresses	Shipping Address	Insert	Change Request		INTERMOUNTAIN SCC ACUTE SERVICES PHARMACY 7268 S BINGHAM JUNCTION BLVD STE A MIDVALE, UT 84047	3/30/2023 4:07 PM
Contacts	Primary Contact	Update	Change Request	Bormann, Rudy E Director of Pharmacy SCL Health 9702982460	Bormann, Rudy E Director of Pharmacy SCL Health 9702982460	12/5/2022 12:07 AM
Addresses	Shipping Address	Insert	Change Request		St. Mary's Hospital and Medical Center, Inc 2635 N. 7th Street Grand Junction, CO 81501	10/19/2022 11:57 AM
Addresses	Shipping Address	Insert	Change Request		St. Mary's Medical Center Cancer Centers of Colorado Pharmacy 750 Wellington Avenue Grand Junction, CO 81501	10/19/2022 11:57 AM
Contacts	Authorizing Official	Update	Change Request	Chinn, Terri CFO SCL Health 9702982020	Chinn, Terri VP of Finance SCL Health 9702982020	9/22/2022 8:20 AM
Details	Last Recertification Date	Update	Recertification	9/7/2021 12:41:09 PM	9/7/2022 7:12:38 AM	9/7/2022 7:12 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 7:53:26 AM	9/7/2021 12:41:09 PM	9/7/2021 12:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1124274436 (UT)		9/22/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1699716027 (UT)		9/22/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1821647801 (UT)		9/22/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1124274436 (WY)		9/22/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1699716027 (WY)		9/22/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1821647801 (WY)		9/22/2020 2:42 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1821647801 ( )		8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1124274436	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1699716027	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821647801	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1124274436	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1699716027	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821647801	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1124274436	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1699716027	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821647801	8/27/2020 7:53 AM
Medicaid Billing	NPI: State	Insert	Recertification		WY	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1699716027 ( )		8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1124274436 ( )		8/27/2020 7:53 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 10:56:13 AM	8/27/2020 7:53:26 AM	8/27/2020 7:53 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821647801	12/9/2019 2:35 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 2:54:39 PM	8/26/2019 10:56:13 AM	8/26/2019 10:56 AM
Details	Last Recertification Date	Update	Recertification	11/20/2017 12:28:34 PM	8/24/2018 2:54:39 PM	8/24/2018 2:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1699716027	3/12/2018 12:16 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124274436	3/12/2018 12:16 PM
Addresses	Billing Address	Update	Change Request	St Mary’s Hospital and Medical Center Inc. Attn: Accounts Payable P.O. Box 1010 Layfayette, CO 80026	St Mary’s Hospital and Medical Center Inc. Attn: Accounts Payable P.O. Box 1010 Lafayette, CO 80026	3/7/2018 11:19 AM
Addresses	Billing Address	Update	Change Request	St Mary’s Hospital and Medical Center Inc. Attn: Accounts Payable 500 Eldorado Blvd., Bldg 4 Broomfield, CO 80021	St Mary’s Hospital and Medical Center Inc. Attn: Accounts Payable P.O. Box 1010 Layfayette, CO 80026	3/1/2018 5:55 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/20/2017 12:28:34 PM	11/20/2017 12:28 PM
Contacts	Primary Contact	Update	Change Request	Lampton, Maria M. Pharmacy Director 9702982640	Bormann, Rudy E Director of Pharmacy SCL Health 9702982460	10/16/2017 1:23 PM
Contacts	Authorizing Official	Update		Chinn, Terri CFO 9702982020	Chinn, Terri CFO SCL Health 9702982020	10/12/2017 12:03 PM
Contacts	Signed By	Update		Chinn, Terri CFO 9702982020	Chinn, Terri CFO SCL Health 9702982020	10/12/2017 12:03 PM
Contacts	Authorizing Official	Insert			Chinn, Terri CFO 9702982020	8/9/2017 2:40 PM
Contacts	Signed By	Insert			Chinn, Terri CFO 9702982020	8/9/2017 2:40 PM
Addresses	Main Address	Insert			2635 N. 7TH STREET GRAND JUNCTION, CO 81501	8/29/2016 10:35 AM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 10:35 AM
Addresses	Billing Address	Insert			St Mary’s Hospital and Medical Center Inc. Attn: Accounts Payable 500 Eldorado Blvd., Bldg 4 Broomfield, CO 80021	7/11/2016 1:59 PM
Details	Last Recertification Date	Update			8/7/2015 12:00:00 AM	8/7/2015 3:40 PM
Contacts	Primary Contact	Insert			Lampton, Maria M. Pharmacy Director 9702982640	3/20/2015 2:14 PM
Dates	Participating Approval Date	Update			8/29/2014 12:00:00 AM	8/29/2014 11:08 AM
Details	State	Update		Pending	Active	8/29/2014 11:08 AM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	8/29/2014 11:08 AM
Details	340B ID	Update		ONLINE_REG_44817	DSH060023	8/12/2014 1:52 PM
Details	340B ID	Update			ONLINE_REG_44817	7/9/2014 4:57 PM
Details	Last Recertification Date	Insert				7/9/2014 4:57 PM
Details	Grant Number	Insert				7/9/2014 4:57 PM
Details	340B ID	Insert				7/9/2014 4:57 PM
Details	Is Authorizing Official EHB Data	Insert				7/9/2014 4:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/9/2014 4:57 PM
Details	Medicare Provider Number	Insert			060023	7/9/2014 4:57 PM
Details	Entity Name	Insert			ST. MARY'S HOSPITAL & MEDICAL CENTER, INC.	7/9/2014 4:57 PM
Details	Program Code	Insert			DSH	7/9/2014 4:57 PM
Details	Entity Subname	Insert				7/9/2014 4:57 PM
Dates	Participating Approval Date	Insert				7/9/2014 4:57 PM
Details	State	Insert			Pending	7/9/2014 4:57 PM
Dates	Registration Date	Insert			7/9/2014 12:00:00 AM	7/9/2014 4:57 PM
Dates	Signed By Date	Insert			7/9/2014 12:00:00 AM	7/9/2014 4:57 PM
Dates	Start Date	Insert				7/9/2014 4:57 PM
Terminations	Termination Comments	Insert				7/9/2014 4:57 PM
Terminations	Termination Date	Insert				7/9/2014 4:57 PM
Terminations	Termination Effective Date	Insert				7/9/2014 4:57 PM
Terminations	Termination Reason	Insert				7/9/2014 4:57 PM