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AVELLA OF DEER VALLEY, INC. #38
DSH280013 THE NEBRASKA MEDICAL CENTER
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Covered Entity Details
Entity Name
THE NEBRASKA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH280013
Entity Address
989200 Nebraska Medical Center
Omaha, NE 68198
Medicare Provider Number
280013
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
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
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/11/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stephanie Daubert, CFO
(402) 552-2889
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
4/15/2019
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