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AMERITA INC.
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
AMERITA INC.
Pharmacy Address
7307 SOUTH REVERE PARKWAY
SUITE 200
CENTENNIAL, CO 80112-3931
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/23/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Karen Scremin, Interim CFO
(303) 813-5255
Contract Pharmacy Representative
Amerita
Daniel Van Valkenburg, Director 340B Program
(810) 434-2710
Signed By Date
10/14/2019
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