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AVELLA OF DEER VALLEY, INC. #38
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 DEER VALLEY, INC. #38
Pharmacy Address
DBA AVELLA SPECIALTY PHARMACY
24416 N. 19TH AVE
PHOENIX, AZ 85085
Pharmacy Comments
Contract Details
Approval Date
10/4/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/17/2020
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
10/4/2016
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