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AVELLA OF PHOENIX III
DSH030013 YUMA REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
YUMA REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030013
Entity Address
2400 S Avenue A
Yuma, AZ 85364
Medicare Provider Number
030013
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
AVELLA OF PHOENIX III
Pharmacy Address
1101 N CENTRAL AVE., STE. 102
PHOENIX, AZ 85004
Pharmacy Comments
Contract Details
Approval Date
7/25/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2020
Ownership change
Contacts
Covered Entity Signing Official
David Willie, CFO
(928) 336-7015
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/25/2016
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