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INTERMOUNTAIN PHARMACY #05
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 #05
Pharmacy Address
1375 E 19TH AVE
STE 1665
DENVER, CO 80218
Pharmacy Comments
Contract Details
Approval Date
1/7/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sean Fadden, VP, Finance
(303) 425-2410
Contract Pharmacy Representative
SCL Health
Rhiannon Longmore, Pharmacy Business Operations Manager
(303) 272-0922
Signed By Date
1/7/2021
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