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KING SOOPERS PHARMACY #68
CAH061318-01 KREMMLING MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
KREMMLING MEMORIAL HOSPITAL DISTRICT
Subdivision Name
dba Middle Park Health - Granby Campus
Type
Critical Access Hospital
340B ID
CAH061318-01
Entity Address
1000 GRANBY PARK DRIVE SOUTH
GRANBY, CO 80446
Medicare Provider Number
061318
Outpatient Facility Provider Number
Participating Start Date
1/1/2015
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
KING SOOPERS PHARMACY #68
Pharmacy Address
3801 E 120TH AVE
THORNTON, CO 80233
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/23/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Debra Plemmons, CNO
(970) 724-3121
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, payor contracting
(513) 762-4000
Signed By Date
10/13/2020
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