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AVELLA OF PHOENIX III
FQHCLA225K Maricopa County Special Health Care District
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Covered Entity Details
Entity Name
Maricopa County Special Health Care District
Subdivision Name
El Mirage Family Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA225K
Entity Address
12428 W. Thunderbird Road
El MIrage, AZ 85335
Grant Number
LALCS00037
Participating Start Date
4/1/2012
Last Recertification Date
2/14/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
AVELLA OF PHOENIX III
Pharmacy Address
1101 N CENTRAL AVE., STE. 102
PHOENIX, AZ 85004
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kathleen Rhodes, Interim Vice President Ambulatory and Physician Services
(602) 344-5558
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/15/2016
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