Contract Pharmacy Details

AVELLA OF DEER VALLEY
CAH361301-00 Community Memorial Hospital

Covered Entity Details

Entity Name

Community Memorial Hospital

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH361301-00

Entity Address

208 Columbus Street
Hicksville, OH 43526

Medicare Provider Number

361301

Participating Start Date

1/1/2014

Last Recertification Date

8/31/2023

Entity Termination Date

10/1/2024

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

10/13/2015

Contract Begin Date

1/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Michelle Waggoner, CEO
(419) 542-5566

Contract Pharmacy Representative

Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677

Signed By Date

10/13/2015

340B Drug Pricing Program Database