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CITY MARKET PHARMACY #451
DSH060023 St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital
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Covered Entity Details
Entity Name
St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060023
Entity Address
2635 N. 7TH STREET
GRAND JUNCTION, CO 81501
Medicare Provider Number
060023
Participating Start Date
10/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
CITY MARKET PHARMACY #451
Pharmacy Address
630 24 ROAD
GRAND JUNCTION, CO 81505
Pharmacy Comments
Contract Details
Approval Date
9/5/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Terri Chinn, CFO
(970) 298-2020
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/5/2014
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