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ADVENTHEALTH PHARMACY PORTER
DSH060064 Centura Porter Adventist Hospital
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Covered Entity Details
Entity Name
Centura Porter Adventist Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060064
Entity Address
2525 SOUTH DOWNING STREET
DENVER, CO 80210
Medicare Provider Number
060064
Participating Start Date
7/1/2022
Last Recertification Date
8/29/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
ADVENTHEALTH PHARMACY PORTER
Pharmacy Address
2525 S DOWNING ST FL 1
DENVER, CO 80210
Pharmacy Comments
Contract Details
Approval Date
4/27/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Matthew P. Leary, Market VFO
(303) 643-1022
Contract Pharmacy Representative
Centura Health
Jon Campbell, Pharmacy Operations Manager
(303) 426-2073
Signed By Date
4/12/2022
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