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AVELLA OF DEER VALLEY
DSH320002 ST. VINCENT HOSPITAL
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Covered Entity Details
Entity Name
ST. VINCENT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320002
Entity Address
455 ST. MICHAELS DRIVE
SANTA FE, NM 87505
Medicare Provider Number
320002
Participating Start Date
1/1/2014
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
1/15/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Patrick B. Carrier, President & CEO
(505) 913-5202
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
1/15/2016
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