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AVELLA OF TUCSON
DSH030111 Banner – University Medical Center South
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Covered Entity Details
Entity Name
Banner – University Medical Center South
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030111
Entity Address
2800 EAST AJO WAY
TUCSON, AZ 85713
Medicare Provider Number
030111
Participating Start Date
4/1/2006
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
AVELLA OF TUCSON
Pharmacy Address
4512 E CAMP LOWELL DR
TUCSON, AZ 85712-1282
Pharmacy Comments
Contract Details
Approval Date
3/11/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/26/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Misty Hanson, CFO
(520) 694-4091
Contract Pharmacy Representative
Keith Cook, President
(623) 742-1701
Signed By Date
3/1/2013
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