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INTERMOUNTAIN HEALTH SAINT JOSEPH HOSPIT
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 HEALTH SAINT JOSEPH HOSPIT
Pharmacy Address
1825 MARION ST
DENVER, CO 80218
Pharmacy Comments
Contract Details
Approval Date
4/13/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Karen Scremin, Interim CFO
(303) 813-5255
Contract Pharmacy Representative
SCL Health
Chris Wilson, Pharmacy Manager
(303) 318-1313 Ext: 61313
Signed By Date
4/13/2015
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