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INTERMOUNTAIN HEALTH GOOD SAMARITAN HOSP
DSH060028 Saint Joseph Hospital, Inc. DBA Intermountain Health Saint Joseph Hospital
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Covered Entity Details
Entity Name
Saint Joseph Hospital, Inc. DBA Intermountain Health Saint Joseph Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060028
Entity Address
1375 EAST 19TH AVENUE
DENVER, CO 80218
Medicare Provider Number
060028
Participating Start Date
7/1/2016
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
7/13/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/23/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Forest C. Binder, Chief Financial Officer
(303) 812-4926
Contract Pharmacy Representative
Nicole Gacnik, Pharmacy Supervisor
(303) 689-6100
Signed By Date
7/13/2016
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