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KING SOOPERS PHARMACY #81
DSH060004 Brighton Community Hospital Association DBA: Intermountain Health Platte Valley Hospital
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Covered Entity Details
Entity Name
Brighton Community Hospital Association DBA: Intermountain Health Platte Valley Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060004
Entity Address
1600 PRAIRIE CENTER PKWY.
BRIGHTON, CO 80601
Medicare Provider Number
060004
Participating Start Date
4/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
KING SOOPERS PHARMACY #81
Pharmacy Address
500 BROMLEY LANE
BRIGHTON, CO 80601
Pharmacy Comments
Contract Details
Approval Date
12/28/2011
Contract Begin Date
12/28/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Harold Dupper, CFO
(303) 498-1601
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
12/19/2011
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