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AVELLA OF TUCSON
DSH030065 BANNER DESERT MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER DESERT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030065
Entity Address
1400 SOUTH DOBSON ROAD
MESA, AZ 85202
Medicare Provider Number
030065
Participating Start Date
1/1/2007
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
7/27/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/5/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Trent S. Blain, Sr Dir Finance
(602) 839-5114
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/27/2015
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