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DIPLOMAT SPECIALTY PHARMACY OF FT LAUDER
DSH270049 Intermountain Health St Vincent Regional Hospital
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Covered Entity Details
Entity Name
Intermountain Health St Vincent Regional Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH270049
Entity Address
1233 N. 30th Street
Billings, MT 59101
Medicare Provider Number
270049
Participating Start Date
10/1/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY OF FT LAUDER
Pharmacy Address
DIPLOMAT SPECIALTY PHARMACY
15471 SW 12TH ST
STE 207
SUNRISE, FL 33326
Pharmacy Comments
Contract Details
Approval Date
1/14/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ron Oldfield, CFO
(406) 237-3314
Contract Pharmacy Representative
Diplomat
Dwayne Dodd, National Sales Manager- 340B, Hospital/Health Systems
(734) 674-0050
Signed By Date
1/14/2016
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