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THE KROGER CO., KS 113
CH083950 MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC
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Covered Entity Details
Entity Name
MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC
Subdivision Name
Mountainlands Community Health Center Main Site Clinic
Type
HRSA-Funded Health Center
340B ID
CH083950
Entity Address
589 S. State Street
Provo, UT 84606-5056
Grant Number
H80CS00213
Participating Start Date
7/1/1995
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
THE KROGER CO., KS 113
Pharmacy Address
1220 S. LIPAN STREET
DENVER, CO 80223
Pharmacy Comments
Contract Details
Approval Date
1/13/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/17/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Todd Bailey, Executive Director
(801) 429-2000 Ext: 1155
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/13/2020
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