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INTERMOUNTAIN HEALTH GOOD SAMARITAN HOSP
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
INTERMOUNTAIN HEALTH GOOD SAMARITAN HOSP
Pharmacy Address
PHARMACY DEPT
200 EXEMPLA CIR
LAFAYETTE, CO 80026
Pharmacy Comments
Contract Details
Approval Date
10/8/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/14/2019
Ownership change
Contacts
Covered Entity Signing Official
Terri Chinn, CFO
(970) 298-2020
Contract Pharmacy Representative
Doug Malcolm, Pharmacy Manager
(303) 689-4996
Signed By Date
10/8/2015
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