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INTERMOUNTAIN PHARMACY #07
DSH060009 Intermountain Health Lutheran Hospital
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Covered Entity Details
Entity Name
Intermountain Health Lutheran Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060009
Entity Address
12911 W 40th Ave
WHEAT RIDGE, CO 80401
Medicare Provider Number
060009
Participating Start Date
4/1/2015
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
7/18/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Karen Scremin, Interim CFO
(303) 813-5255
Contract Pharmacy Representative
SCL Health
Rhiannon Longmore, Pharmacy Business Operations Manager
(303) 272-0922
Signed By Date
7/18/2018
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