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AVELLA OF DEER VALLEY
FQHCLA225X Maricopa County Special Health Care District
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Covered Entity Details
Entity Name
Maricopa County Special Health Care District
Subdivision Name
Pendergast Family Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA225X
Entity Address
10550 W Mariposa Street
Phoenix, AZ 85037
Grant Number
LALCS00037
Participating Start Date
1/1/2016
Last Recertification Date
2/8/2018
Entity Termination Date
10/1/2018
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
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
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
7/15/2016
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