Covered Entity Details

DSH060009C Intermountain Health Lutheran Hospital (Terminated) - information as of 5/4/2025 10:15:55 PM

Main Details

Name

Intermountain Health Lutheran Hospital

Subdivision Name

WEST PINES BEHAVIORAL HEALTH

Type

Disproportionate Share Hospital

Rural

340B ID

DSH060009C

Medicare Provider Number

060009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/15/2015

Participating Start Date

1/1/2016

Participating Approval Date

10/30/2015

Last Recertification Date

8/20/2024

Termination Date
Termination Reason

4/1/2025
Site closure

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

3400 LUTHERAN PKWY
WHEAT RIDGE, CO 80033-6035

Billing Address

Lutheran Medical Center ATTN: Accounts Payable
P.O. 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

Shipping Address 1

Lutheran Medical Center
8300 W. 38th Ave
Wheat Ridge, CO 80033

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
No records to display.

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	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/7/2025 12:00:00 AM	3/10/2025 12:31 PM
Details	State	Update	Termination Request	Active	To Be Terminated	3/10/2025 12:31 PM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	3/10/2025 12:31 PM
Terminations	Termination Effective Date	Update	Termination Request		3/10/2025 12:00:00 AM	3/10/2025 12:31 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	3/10/2025 12:31 PM
Details	Last Recertification Date	Update	Recertification	8/15/2023 10:32:18 AM	8/20/2024 11:45:42 AM	8/20/2024 11:45 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 3:08:44 PM	8/15/2023 10:32:18 AM	8/15/2023 10:32 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 5:37:50 PM	9/7/2022 3:08:44 PM	9/7/2022 3:08 PM
Addresses	Billing Address	Insert	Group Change Request		Lutheran Medical Center ATTN: Accounts Payable P.O. 1010 Lafayette, CO 80026	1/25/2022 7:30 AM
Addresses	Shipping Address	Insert	Group Change Request		Lutheran Medical Center 8300 W. 38th Ave Wheat Ridge, CO 80033	1/25/2022 7:30 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 3:21:08 PM	9/2/2021 5:37:50 PM	9/2/2021 5:37 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/28/2020 3:21 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/28/2020 3:21 PM
Medicaid Billing	NPI: State	Update	Recertification		CO	8/28/2020 3:21 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 11:36:45 AM	8/28/2020 3:21:08 PM	8/28/2020 3:21 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 11:19:50 AM	8/22/2019 11:36:45 AM	8/22/2019 11:36 AM
Details	Last Recertification Date	Update	Recertification	11/30/2017 6:52:38 PM	8/16/2018 11:19:50 AM	8/16/2018 11:19 AM
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
Details	Entity Name	Update	Recertification	LUTHERAN MEDICAL CENTER	LUTHERAN MEDICAL CENTER	12/1/2017 7:20 AM
Contacts	Primary Contact	Update	Recertification	Ramzy, Nagy Director of Pharmacy 3034033553	Cardona, Jason Director of Pharmacy Lutheran Medical Center 3034252049	11/30/2017 6:52 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/30/2017 6:52:38 PM	11/30/2017 6:52 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			3400 LUTHERAN PKWY WHEAT RIDGE, CO 80033-6035	11/15/2016 3:17 PM
Details	Entity Name	Update		EXEMPLA LUTHERAN MEDICAL CENTER	LUTHERAN MEDICAL CENTER	11/15/2016 3:17 PM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 2:34 PM
Contacts	Primary Contact	Insert			Ramzy, Nagy Director of Pharmacy 3034033553	10/30/2015 2:22 PM
Dates	Participating Approval Date	Update			10/30/2015 12:00:00 AM	10/30/2015 2:17 PM
Details	State	Update		Pending	Active	10/30/2015 2:17 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	10/30/2015 2:17 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_56137	DSH060009C	10/27/2015 12:36 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_56137	10/15/2015 4:05 PM
Details	Last Recertification Date	Insert				10/15/2015 4:05 PM
Details	Grant Number	Insert				10/15/2015 4:05 PM
Details	340B ID	Insert				10/15/2015 4:05 PM
Details	Is Authorizing Official EHB Data	Insert				10/15/2015 4:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/15/2015 4:05 PM
Details	Medicare Provider Number	Insert			060009	10/15/2015 4:05 PM
Details	Entity Name	Insert			EXEMPLA LUTHERAN MEDICAL CENTER	10/15/2015 4:05 PM
Details	Program Code	Insert			DSH	10/15/2015 4:05 PM
Details	Entity Subname	Insert			WEST PINES BEHAVIORAL HEALTH	10/15/2015 4:05 PM
Dates	Participating Approval Date	Insert				10/15/2015 4:05 PM
Details	State	Insert			Pending	10/15/2015 4:05 PM
Dates	Registration Date	Insert			10/15/2015 12:00:00 AM	10/15/2015 4:05 PM
Dates	Signed By Date	Insert			10/15/2015 12:00:00 AM	10/15/2015 4:05 PM
Dates	Start Date	Insert				10/15/2015 4:05 PM
Terminations	Termination Comments	Insert				10/15/2015 4:05 PM
Terminations	Termination Date	Insert				10/15/2015 4:05 PM
Terminations	Termination Effective Date	Insert				10/15/2015 4:05 PM
Terminations	Termination Reason	Insert				10/15/2015 4:05 PM