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AVELLA OF DEER VALLEY
CAH161380-00 ELLSWORTH MUNICIPAL HOSPITAL
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Covered Entity Details
Entity Name
ELLSWORTH MUNICIPAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161380-00
Entity Address
920 S OAK ST
DBA HANSEN FAMILY HOSPITAL
IOWA FALLS, IA 50126-9506
Medicare Provider Number
161380
Participating Start Date
9/1/2010
Last Recertification Date
8/21/2024
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
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/2/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane Deblon, CFO
(563) 547-6677
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/17/2017
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