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AVELLA OF DEER VALLEY
DSH450237 SANTA ROSA HEALTHCARE
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Covered Entity Details
Entity Name
SANTA ROSA HEALTHCARE
Subdivision Name
CHRISTUS SANTA ROSA HOSPITAL MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH450237
Entity Address
2827 BABCOCK ROAD
SAN ANTONIO, TX 78229
Medicare Provider Number
450237
Participating Start Date
7/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
AVELLA OF DEER VALLEY
Pharmacy Address
23620 N 20TH DR #12
PHOENIX, AZ 85085-0621
Pharmacy Comments
Contract Details
Approval Date
1/25/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Contacts
Covered Entity Signing Official
Linda Kirks, Regional VP/CFO
(210) 704-2624
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
1/25/2016
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