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AVELLA OF DEER VALLEY, INC. #38
STD891011 John Phoenix APRN, PLLC
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Covered Entity Details
Entity Name
John Phoenix APRN, PLLC
Subdivision Name
Huntridge Family Clinic
Type
Sexually Transmitted Diseases
340B ID
STD891011
Entity Address
The Gay and Lesbian Center
401 S. Maryland Parkway
Las Vegas, NV 89101
Grant Number
5 NH25PS005179-02-00
Participating Start Date
4/1/2020
Last Recertification Date
5/10/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
AVELLA OF DEER VALLEY, INC. #38
Pharmacy Address
24416 N. 19TH AVE
PHOENIX, AZ 85085-1887
Pharmacy Comments
Contract Details
Approval Date
3/5/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Phoenix, Chief Clinical Officer
(702) 979-1111
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/6/2020
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