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AVELLA OF ORLANDO
DSH140180 Presence Saints Mary and Elizabeth Medical Center
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Covered Entity Details
Entity Name
Presence Saints Mary and Elizabeth Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140180
Entity Address
2233 WEST DIVISION STREET
CHICAGO, IL 60622
Medicare Provider Number
140180
Participating Start Date
7/1/2003
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
AVELLA OF ORLANDO
Pharmacy Address
100 TECHNOLOGY PARK STE 155
LAKE MARY, FL 32746-6205
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Benner, System Vice President, Pharmacy and Laboratory Services
(630) 914-2842
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
1/15/2018
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