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AVELLA OF DEER VALLEY
CAH381321-00 Grande Ronde Hospital, Inc.
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Covered Entity Details
Entity Name
Grande Ronde Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381321-00
Entity Address
900 Sunset Drive
La Grande, OR 97850
Medicare Provider Number
381321
Participating Start Date
4/1/2013
Last Recertification Date
8/20/2024
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
4/8/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/3/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Wade E. Weis, Sr. Director of Finance/CFO
(541) 963-1463
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/8/2015
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