Contract Pharmacy Details

AVELLA OF DEER VALLEY, INC. #38
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY

Covered Entity Details

Entity Name

SSM HEALTH-ST. MARYS-JEFFERSON CITY

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH260011

Entity Address

2505 Mission Drive
JEFFERSON CITY, MO 65109

Medicare Provider Number

260011

Participating Start Date

7/1/2022

Last Recertification Date

9/1/2024

Entity Termination Date

7/1/2025

Pharmacy Details

Pharmacy Name

AVELLA OF DEER VALLEY, INC. #38

Pharmacy Address

24416 N. 19TH AVE.
ATTEN: TERI KINZLE
PHOENIX, AZ 85085-1877

Pharmacy Comments

Contract Details

Approval Date

1/25/2021

Contract Begin Date

1/25/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2021
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Becky Miller, Vice President-Hospital Operations
(573) 681-3136

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

1/14/2021

340B Drug Pricing Program Database