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AVELLA OF COLUMBUS
DSH180093A Baptist Health Deaconess Madisonville
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Covered Entity Details
Entity Name
Baptist Health Deaconess Madisonville
Subdivision Name
MAHR CANCER CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH180093A
Entity Address
900 HOSPITAL DRIVE
MADISONVILLE, KY 42431
Medicare Provider Number
180093
Outpatient Facility Provider Number
Participating Start Date
1/1/2005
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
AVELLA OF COLUMBUS
Pharmacy Address
4830 KNIGHTSBRIDGE BLVD STE C
COLUMBUS, OH 43214-2300
Pharmacy Comments
Contract Details
Approval Date
1/6/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/11/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Ashby, Vice President of Finance
(270) 825-5781
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
1/6/2016
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