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AVELLA OF DEER VALLEY
DSH330350 UNIVERSITY HOSPITAL OF BROOKLYN
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL OF BROOKLYN
Subdivision Name
SUNY DOWNSTATE MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH330350
Entity Address
445 LENOX ROAD
Attn: Pharmacy Box 36
BROOKLYN, NY 11203
Medicare Provider Number
330350
Participating Start Date
12/1/1992
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
AVELLA OF DEER VALLEY
Pharmacy Address
23620 N 20TH DR #12
PHOENIX, AZ 85085-0621
Pharmacy Comments
Contract Details
Approval Date
4/6/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/20/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
William Walsh, CEO
(718) 270-4293
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/6/2015
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