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INTERMOUNTAIN PHARMACY #09
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 #09
Pharmacy Address
12911 W 40TH AVE
WHEAT RIDGE, CO 80401
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
8/3/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ashley Denton, VP Finance
(303) 425-2410
Contract Pharmacy Representative
Intermountain Healthcare
Carrie Dunford, Chief Pharmacy Officer
(801) 284-1004
Signed By Date
7/15/2024
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