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INTERMOUNTAIN PHARMACY #07
DSH060028 Saint Joseph Hospital, Inc. DBA Intermountain Health Saint Joseph Hospital
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Covered Entity Details
Entity Name
Saint Joseph Hospital, Inc. DBA Intermountain Health Saint Joseph Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060028
Entity Address
1375 EAST 19TH AVENUE
DENVER, CO 80218
Medicare Provider Number
060028
Participating Start Date
7/1/2016
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
INTERMOUNTAIN PHARMACY #07
Pharmacy Address
200 EXEMPLA CIR STE P1-142
LAFAYETTE, CO 80026
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Alice Rigdon, VP Finance
(303) 812-4926
Contract Pharmacy Representative
SCLHS
Daniel Madrid, Outpatient Pharmacy
(303) 689-6121
Signed By Date
7/17/2018
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