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INTERMOUNTAIN HEALTH GOOD SAMARITAN HOSP
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 GOOD SAMARITAN HOSP
Pharmacy Address
PHARMACY DEPT
200 EXEMPLA CIR
LAFAYETTE, CO 80026
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/11/2019
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
Rhiannon Longmore, Pharmacy Business Operations Manager
(303) 272-0922
Signed By Date
10/15/2015
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