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AVELLA OF DEER VALLEY
DSH190020 LANE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LANE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190020
Entity Address
6300 MAIN STREET
ZACHARY, LA 70791
Medicare Provider Number
190020
Participating Start Date
4/1/2008
Last Recertification Date
8/28/2024
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
1/15/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/2/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Anderson, Chief Financial Officer
(225) 658-4302
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
1/15/2016
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