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AVELLA OF DEER VALLEY
CAH051319-00 DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA
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Covered Entity Details
Entity Name
DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051319-00
Entity Address
914 PINE STREET.
MOUNT SHASTA, CA 96067
Medicare Provider Number
051319
Participating Start Date
9/8/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
AVELLA OF DEER VALLEY
Pharmacy Address
23620 N 20TH DR #12
PHOENIX, AZ 85085-0621
Pharmacy Comments
Contract Details
Approval Date
7/16/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Miranda, CFO
(916) 453-4459
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/16/2018
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