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AVELLA OF ST LOUIS
DSH150169 COMMUNITY HOSPITAL OF INDIANA INC.
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Covered Entity Details
Entity Name
COMMUNITY HOSPITAL OF INDIANA INC.
Subdivision Name
Community Hospital North
Type
Disproportionate Share Hospital
340B ID
DSH150169
Entity Address
7150 CLEARVISTA DRIVE
INDIANAPOLIS, IN 46256
Medicare Provider Number
150169
Participating Start Date
4/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
AVELLA OF ST LOUIS
Pharmacy Address
450 N NEW BALLAS RD STE 256
SAINT LOUIS, MO 63141-6836
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Dee Moonesinghe, Physician Executive
(765) 437-2959
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/12/2019
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