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KING SOOPERS #124
DSH060107 NATIONAL JEWISH MEDICAL AND RESEARCH CENTER
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Covered Entity Details
Entity Name
NATIONAL JEWISH MEDICAL AND RESEARCH CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060107
Entity Address
1400 JACKSON STREET
DENVER, CO 80206
Medicare Provider Number
060107
Participating Start Date
10/1/2004
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
KING SOOPERS #124
Pharmacy Address
4600 LEETSDALE
GLENDALE, CO 80246
Pharmacy Comments
Contract Details
Approval Date
7/12/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHRISTINE FORKNER, CFO
(303) 398-1004
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/12/2016
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