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AVELLA OF PHOENIX II
DSH050045 EL CENTRO REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
EL CENTRO REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050045
Entity Address
1415 ROSS AVENUE
EL CENTRO, CA 92243
Medicare Provider Number
050045
Participating Start Date
10/1/2006
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
AVELLA OF PHOENIX II
Pharmacy Address
5040 N 15TH AVE #102
PHOENIX, AZ 85015
Pharmacy Comments
Contract Details
Approval Date
10/15/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/29/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ALEX WELLS, CFO
(760) 370-3774
Contract Pharmacy Representative
Keith Cook, President
(623) 742-1701
Signed By Date
10/15/2013
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