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AVELLA OF DEER VALLEY
PED033302-00 PHOENIX CHILDREN'S HOSPITAL
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Covered Entity Details
Entity Name
PHOENIX CHILDREN'S HOSPITAL
Subdivision Name
Type
Children's Hospital
340B ID
PED033302-00
Entity Address
1919 E THOMAS ROAD
PHOENIX, AZ 85016
Medicare Provider Number
033302
Participating Start Date
4/1/2010
Last Recertification Date
9/19/2024
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
10/29/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/26/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CRAIG MCKNIGHT, CFO
(602) 546-5468
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
10/29/2015
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