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INTERMOUNTAIN HEALTH SAINT JOSEPH HOSPIT
DSH060009A Intermountain Health Lutheran Hospital
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Covered Entity Details
Entity Name
Intermountain Health Lutheran Hospital
Subdivision Name
Lutheran Medical Center - Cancer Centers of Colorado - Infusion Center
Type
Disproportionate Share Hospital
340B ID
DSH060009A
Entity Address
400 Indiana Street, Ste 310
INFUSION CENTER
Golden, CO 80401-6013
Medicare Provider Number
060009
Outpatient Facility Provider Number
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
3/18/2019
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
Chris Wilson, Pharmacy Manager
(303) 318-1313 Ext: 61313
Signed By Date
4/13/2015
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