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AVELLA OF DEER VALLEY, INC. #38
CAH181310-01 CARROLL COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CARROLL COUNTY MEMORIAL HOSPITAL
Subdivision Name
CARROLL COUNTY RURAL HEALTH CLINIC
Type
Critical Access Hospital
340B ID
CAH181310-01
Entity Address
309 11TH STREET
CARROLLTON, KY 41008
Medicare Provider Number
181310
Outpatient Facility Provider Number
Participating Start Date
10/1/2011
Last Recertification Date
8/12/2024
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
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Harry Hays, CEO
(502) 732-3200
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
10/12/2018
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