Covered Entity Details

DSH060009A Intermountain Health Lutheran Hospital (Active) - information as of 4/28/2025 1:48:37 AM

Main Details

Name

Intermountain Health Lutheran Hospital

Subdivision Name

Lutheran Medical Center - Cancer Centers of Colorado - Infusion Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH060009A

Medicare Provider Number

060009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/12/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/4/2015

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

SCL Health Lutheran Medical Center
Ashley Denton, VP Finance
(303) 425-2410

Primary Contact

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

Addresses

Street Address

400 Indiana Street, Ste 310
INFUSION CENTER
Golden, CO 80401-6013

Billing Address

LUTHERAN MEDICAL CENTER
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		1669461281,1629053731,1255360301,1235803917,1699449371

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	INTERMOUNTAIN HEALTH SAINT JOSEPH HOSPIT	1825 MARION ST		DENVER	CO	80218	04/13/2015	07/01/2015		03/18/2019	03/18/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH060009A	Child	DSH	Intermountain Health Lutheran Hospital	Lutheran Medical Center - Cancer Centers of Colorado - Infusion Center	400 Indiana Street, Ste 310	Golden	CO	Active
DSH060009B	Child	DSH	LUTHERAN MEDICAL CENTER	LMC Pulmonary Rehabilitation	9830 I-70 FRONTAGE RD S	WHEAT RIDGE	CO	Terminated
DSH060009C	Child	DSH	Intermountain Health Lutheran Hospital	WEST PINES BEHAVIORAL HEALTH	3400 LUTHERAN PKWY	WHEAT RIDGE	CO	Terminated
DSH060009D	Child	DSH	Intermountain Health Lutheran Hospital	HOSPICE	3210 LUTHERAN PARKWAY	WHEAT RIDGE	CO	Active
DSH060009E	Child	DSH	Intermountain Health Lutheran Hospital	Lutheran Medical Center - Cancer Centers of Colorado - Medical Oncology	400 Indiana Street, Ste 300	Golden	CO	Active
DSH060009F	Child	DSH	Intermountain Health Lutheran Hospital	SCL HEALTH FRONT RANGE INC - LMC EWP BH Outpatient Therapy	3400 LUTHERAN PKWY	WHEAT RIDGE	CO	Terminated
DSH060009G	Child	DSH	Intermountain Health Lutheran Hospital	SCL HEALTH FRONT RANGE INC - LMC EWP Psychiatric Day Care	3400 LUTHERAN PKWY	WHEAT RIDGE	CO	Terminated
DSH060009H	Child	DSH	Intermountain Health Lutheran Hospital	SCL HEALTH FRONT RANGE INC - LMC WP Chemical Dependency Recovery	3400 LUTHERAN PKWY	WHEAT RIDGE	CO	Terminated
DSH060009J	Child	DSH	Intermountain Health Lutheran Hospital	SCL HEALTH FRONT RANGE INC - LMC Hospice Outpatient	3210 LUTHERAN PKWY	WHEAT RIDGE	CO	Active
DSH060009K	Child	DSH	Intermountain Health Lutheran Hospital	SCL HEALTH FRONT RANGE INC - Chemical Dependency Intensive Outpatient Program	3400 LUTHERAN PKWY	WHEAT RIDGE	CO	Terminated
DSH060009L	Child	DSH	Intermountain Health Lutheran Hospital	Coumadin Clinic - Ambulatory Clinical Services	2905 W 40th Ave, Suite 215	Wheat Ridge	CO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 10:27:15 AM	8/20/2024 11:46:17 AM	8/20/2024 11:46 AM
Details	Entity Name	Update	Change Request	LUTHERAN MEDICAL CENTER	Intermountain Health Lutheran Hospital	8/5/2024 2:03 PM
Contacts	Primary Contact	Update	Group Change Request	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	Landry, Ben 340B Pharmacist Intermountain Health 2072005264	4/30/2024 7:25 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 3:09:16 PM	8/15/2023 10:27:15 AM	8/15/2023 10:27 AM
Contacts	Primary Contact	Update	Group Change Request	Cardona, Jason Director of Pharmacy SCL Health 3034252049	Stubbs, Charles B. 340B Pharmacist Intermountain Healthcare 8012841113	6/29/2023 12:29 PM
Contacts	Primary Contact	Update	Group Change Request	Cardona, Jason Director of Pharmacy Lutheran Medical Center 3034252049	Cardona, Jason Director of Pharmacy SCL Health 3034252049	12/21/2022 6:29 AM
Details	Last Recertification Date	Update	Recertification	9/2/2021 5:39:07 PM	9/7/2022 3:09:16 PM	9/7/2022 3:09 PM
Addresses	Main Address	Update	Change Request	3550 LUTHERAN PARKWAY STE 100 THE INFUSION CARE CENTER WHEAT RIDGE, CO 80033-6013	400 Indiana Street, Ste 310 INFUSION CENTER Golden, CO 80401-6013	3/1/2022 9:05 AM
Details	Entity Subname	Update	Change Request	Lutheran Medical Center - Cancer Centers of Colorado - Infusion	Lutheran Medical Center - Cancer Centers of Colorado - Infusion Center	3/1/2022 9:05 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1235803917	1/10/2022 3:22 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	1/10/2022 3:22 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1699449371	1/10/2022 3:22 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	1/10/2022 3:22 PM
Contacts	Authorizing Official	Update	Change Request	Fadden, Sean VP, Finance Lutheran Medical Center 3034252410	Denton, Ashley VP Finance SCL Health Lutheran Medical Center 3034252410	9/24/2021 2:05 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 3:18:17 PM	9/2/2021 5:39:07 PM	9/2/2021 5:39 PM
Addresses	Billing Address	Insert	Change Request		LUTHERAN MEDICAL CENTER P.O. Box 1010 Lafayette, CO 80026	11/4/2020 12:49 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/28/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/28/2020 3:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/28/2020 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 11:37:10 AM	8/28/2020 3:18:17 PM	8/28/2020 3:18 PM
Contacts	Authorizing Official	Update	Change Request	Scremin, Karen Interim CFO SCL Health 3038135255	Fadden, Sean VP, Finance Lutheran Medical Center 3034252410	1/15/2020 1:11 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 11:21:08 AM	8/22/2019 11:37:10 AM	8/22/2019 11:37 AM
Addresses	Main Address	Update	Change Request	3550 LUTHERAN PARKWAY STE 100-B THE INFUSION CARE CENTER WHEAT RIDGE, CO 80033-6013	3550 LUTHERAN PARKWAY STE 100 THE INFUSION CARE CENTER WHEAT RIDGE, CO 80033-6013	2/7/2019 7:02 AM
Details	Entity Subname	Update	Change Request	LMC Infusion Center	Lutheran Medical Center - Cancer Centers of Colorado - Infusion	2/7/2019 7:02 AM
Details	Last Recertification Date	Update	Recertification	11/30/2017 6:51:34 PM	8/16/2018 11:21:08 AM	8/16/2018 11:21 AM
Addresses	Main Address	Update	Change Request	3550 LUTHERAN PARKWAY STE G-25 THE INFUSION CARE CENTER WHEAT RIDGE, CO 80033-6013	3550 LUTHERAN PARKWAY STE 100-B THE INFUSION CARE CENTER WHEAT RIDGE, CO 80033-6013	4/24/2018 3:55 PM
Details	Entity Subname	Update	Change Request	LMC Infusion Center	LMC Infusion Center	4/24/2018 3:55 PM
Contacts	Authorizing Official	Update	Change Request	Doyle, James M. VP of Finance SCL Health 3034252410	Scremin, Karen Interim CFO SCL Health 3038135255	1/4/2018 1:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669461281	12/15/2017 5:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629053731	12/15/2017 5:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1255360301	12/15/2017 5:59 PM
Contacts	Primary Contact	Insert	Recertification		Cardona, Jason Director of Pharmacy Lutheran Medical Center 3034252049	11/30/2017 6:51 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/30/2017 6:51:34 PM	11/30/2017 6:51 PM
Contacts	Authorizing Official	Update		Doyle, James M. VP of Finance 3034252410	Doyle, James M. VP of Finance SCL Health 3034252410	11/30/2017 6:41 PM
Contacts	Signed By	Update		Scremin, Karen Interim CFO 3038135255	Scremin, Karen Interim CFO SCL Health 3038135255	10/11/2017 12:53 PM
Contacts	Authorizing Official	Insert			Doyle, James M. VP of Finance 3034252410	7/12/2017 10:57 AM
Contacts	Signed By	Insert			Scremin, Karen Interim CFO 3038135255	6/28/2017 12:44 PM
Addresses	Main Address	Insert			3550 LUTHERAN PARKWAY STE G-25 THE INFUSION CARE CENTER WHEAT RIDGE, CO 80033-6013	11/15/2016 3:17 PM
Details	Entity Name	Update		EXEMPLA LUTHERAN MEDICAL CENTER	LUTHERAN MEDICAL CENTER	11/15/2016 3:17 PM
Details	Entity Subname	Update		EXEMPLA INC. / LMC Infusion Center	LMC Infusion Center	11/15/2016 3:17 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 2:34 PM
Details	Last Recertification Date	Update			8/6/2015 12:00:00 AM	8/6/2015 5:26 PM
Dates	Participating Approval Date	Update			3/4/2015 12:00:00 AM	3/4/2015 2:39 PM
Details	State	Update		Pending	Active	3/4/2015 2:39 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/4/2015 2:39 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_48748	DSH060009A	2/3/2015 2:57 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48748	1/12/2015 3:29 PM
Details	Last Recertification Date	Insert				1/12/2015 3:29 PM
Details	Grant Number	Insert				1/12/2015 3:29 PM
Details	340B ID	Insert				1/12/2015 3:29 PM
Details	Is Authorizing Official EHB Data	Insert				1/12/2015 3:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2015 3:29 PM
Details	Medicare Provider Number	Insert			060009	1/12/2015 3:29 PM
Details	Entity Name	Insert			EXEMPLA LUTHERAN MEDICAL CENTER	1/12/2015 3:29 PM
Details	Program Code	Insert			DSH	1/12/2015 3:29 PM
Details	Entity Subname	Insert			EXEMPLA INC. / LMC Infusion Center	1/12/2015 3:29 PM
Dates	Participating Approval Date	Insert				1/12/2015 3:29 PM
Details	State	Insert			Pending	1/12/2015 3:29 PM
Dates	Registration Date	Insert			1/12/2015 12:00:00 AM	1/12/2015 3:29 PM
Dates	Signed By Date	Insert			1/12/2015 12:00:00 AM	1/12/2015 3:29 PM
Dates	Start Date	Insert				1/12/2015 3:29 PM
Terminations	Termination Comments	Insert				1/12/2015 3:29 PM
Terminations	Termination Date	Insert				1/12/2015 3:29 PM
Terminations	Termination Effective Date	Insert				1/12/2015 3:29 PM
Terminations	Termination Reason	Insert				1/12/2015 3:29 PM