Contract Pharmacy Details

AVELLA OF DEER VALLEY, INC. #38
CAH051319-00 DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA

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, INC. #38

Pharmacy Address

DBA AVELLA SPECIALTY PHARMACY
24416 N. 19TH AVE
PHOENIX, AZ 85085

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

340B Drug Pricing Program Database