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AVELLA OF PHOENIX III
FQHCLA225T Maricopa County Special Health Care District
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Covered Entity Details
Entity Name
Maricopa County Special Health Care District
Subdivision Name
Whole Health Home Clinic PIR East Valley
Type
Health Center Program Look-Alike
340B ID
FQHCLA225T
Entity Address
4330 E. University Drive
Mesa, AZ 85205
Grant Number
LALCS00037
Participating Start Date
4/1/2013
Last Recertification Date
2/8/2018
Entity Termination Date
7/1/2018
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
7/16/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
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
7/16/2016
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