Contract Pharmacy Details

AVELLA OF DEER VALLEY, INC. #38
DSH520136 Ascension SE Wisconsin Hospital, Inc.

Covered Entity Details

Entity Name

Ascension SE Wisconsin Hospital, Inc.

Subdivision Name

ST. JOSEPH CAMPUS

Type

Disproportionate Share Hospital

340B ID

DSH520136

Entity Address

5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210

Medicare Provider Number

520136

Participating Start Date

4/1/2004

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

AVELLA OF DEER VALLEY, INC. #38

Pharmacy Address

DBA AVELLA SPECIALTY PHARMACY
24416 N. 19TH AVE
PHOENIX, AZ 85085

Pharmacy Comments

Contract Details

Approval Date

4/18/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183

Contract Pharmacy Representative

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

Signed By Date

4/18/2018

340B Drug Pricing Program Database