Covered Entity Details

DSH430016J AVERA MCKENNAN (Active) - information as of 5/9/2025 12:18:03 AM

Main Details

Name

AVERA MCKENNAN

Subdivision Name

Avera Medical Group Behavioral Health - Children

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH430016J

Medicare Provider Number

430016

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/12/2009

Participating Start Date

7/1/2009

Participating Approval Date

5/26/2009

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Avera
Melissa Goff, Vice President - Pharmacy
(605) 322-8548

Primary Contact

Avera
Brandy Friesen, Pharmacy Regulatory Analyst
(605) 322-8446

Addresses

Street Address

4400 W 69TH STREET
STE 500
SIOUX FALLS, SD 57108

Billing Address

AVERA MCKENNAN HOSPITAL
PO Box 5045
Sioux Falls, SD 57117

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
10/8/09 UPDATED SUBDIV NAME (WAS AVERA MIDWEST PSYCHIATRIC MEDICINE)	08/05/2010

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Avera McKennan Hospital
1325 S Cliff Avenue
Sioux Falls, SD 57105

Shipping Address 2

AVERA DISTRIBUTION CENTER
3301 N 1ST AVE
SIOUX FALLS, SD 57104

Shipping Address 3

Avera Medical Group Behavioral Health - Children
4400 W 69th Street
Suite 500
Sioux Falls, SD 57108

Shipping Address 4

Avera McKennan dba Avera on Louise Inpatient Pharmacy
6100 S Louise Ave
Suite B300
Sioux Falls, SD 57108

Shipping Address 5

Avera Pharmacy Distribution Center
4101 W Memory Circle, Ste 150
Sioux Falls, SD 57107

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	AVERA MCKENNAN CAMPUS PHARMACY	1325 S CLIFF AVE STE CP		SIOUX FALLS	SD	57105-1008	07/07/2009	07/07/2009		09/14/2020	09/14/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH430016A	Child	DSH	AVERA MCKENNAN	Avera Medical Group Internal Medicine	1301 S CLIFF AVE	SIOUX FALLS	SD	Active
DSH430016AA	Child	DSH	AVERA MCKENNAN	Avera Medical Group Family Medicine - Marion Rd	2100 S Marion Rd	Sioux Falls	SD	Active
DSH430016AB	Child	DSH	AVERA MCKENNAN	Avera Medical Group McGreevy - West Benson Rd	4011 W Benson Rd	Sioux Falls	SD	Active
DSH430016AC	Child	DSH	AVERA MCKENNAN	Avera Medical Group Tea	725 E Figzel Court	Tea	SD	Active
DSH430016AD	Child	DSH	AVERA MCKENNAN	Avera Medical Group Urogynecology	6100 S Louise Ave	Sioux Falls	SD	Active
DSH430016AE	Child	DSH	AVERA MCKENNAN	Avera Brain & Spine Institute	1301 S CLIFF AVE	SIOUX FALLS	SD	Terminated
DSH430016AF	Child	DSH	AVERA MCKENNAN	Avera Medical Group Gastroenterology	6100 S Louise Ave	SIOUX FALLS	SD	Active
DSH430016AG	Child	DSH	AVERA MCKENNAN	Avera Transplant & Liver Surgery	911 E 20th St	Sioux Falls	SD	Active
DSH430016AH	Child	DSH	AVERA MCKENNAN	Avera Medical Group Obstetrics & Gynecology	1417 S CLIFF AVE	SIOUX FALLS	SD	Active
DSH430016AJ	Child	DSH	AVERA MCKENNAN	Avera Medical Group Certified Nurse Midwifery	1417 S CLIFF AVE	Sioux Falls	SD	Active
DSH430016AK	Child	DSH	AVERA MCKENNAN	Avera Medical Group Radiology - Diagnostic	1000 E 23rd Street	Sioux Falls	SD	Active
DSH430016AL	Child	DSH	AVERA MCKENNAN	Avera Medical Group Radiology - CT Scan	1301 S Cliff Ave	Sioux Falls	SD	Active
DSH430016AM	Child	DSH	AVERA MCKENNAN	Avera Medical Group Radiology - PET	1000 E 23rd St	Sioux Falls	SD	Active
DSH430016AN	Child	DSH	AVERA MCKENNAN	Avera Medical Group Internal Medicine Women's Clinic	6215 South Cliff Ave	Sioux Falls	SD	Active
DSH430016AP	Child	DSH	AVERA MCKENNAN	Avera Medical Group Obstetrics & Gynecology - Cliff Ave.	6215 S Cliff Ave	Sioux Falls	SD	Active
DSH430016AQ	Child	DSH	AVERA MCKENNAN	Avera Medical Group Obstetrics & Gynecology- Marion Rd.	2100 S Marion Rd	Sioux Falls	SD	Active
DSH430016AR	Child	DSH	AVERA MCKENNAN	Emergency Department West	2100 S Marion Rd	Sioux Falls	SD	Active
DSH430016AS	Child	DSH	AVERA MCKENNAN	Avera Orthopedics	6100 S Louise Ave	Sioux Falls	SD	Active
DSH430016AT	Child	DSH	AVERA MCKENNAN	Pain Clinic	1301 S Cliff Ave	Sioux Falls	SD	Active
DSH430016AU	Child	DSH	AVERA MCKENNAN	Avera Medical Group Plastic & Reconstructive Surgery	1417 S CLIFF AVE	SIOUX FALLS	SD	Active
DSH430016AV	Child	DSH	AVERA MCKENNAN	Avera Digestive Disease Institute - Endoscopy/Colonoscopy	6100 S Louise Ave	Sioux Falls	SD	Active
DSH430016AW	Child	DSH	AVERA MCKENNAN	Avera Medical Group Orthopedics & Sports Medicine	911 E 20th Street	Sioux Falls	SD	Active
DSH430016AX	Child	DSH	AVERA MCKENNAN	McKennan Outpatient Infusion	1417 S Cliff Avenue	Sioux Falls	SD	Active
DSH430016AY	Child	DSH	AVERA MCKENNAN	Avera Medical Group Internal Medicine - Louise Ave	6100 S. Louise Ave	Sioux Falls	SD	Active
DSH430016AZ	Child	DSH	AVERA MCKENNAN	Avera Medical Group Infectious Disease Specialists	6709 S Minnesota Ave	Sioux Falls	SD	Active
DSH430016B	Child	DSH	AVERA MCKENNAN	Avera Medical Group Oncology & Hematology	1000 E 23RD ST	SIOUX FALLS	SD	Active
DSH430016BA	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Maternal Fetal Medicine	1417 S Cliff Ave	Sioux Falls	SD	Active
DSH430016BB	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Pediatric Specialists	1417 S Cliff Avenue	Sioux Falls	SD	Active
DSH430016BC	Child	DSH	AVERA MCKENNAN	Neuro Endovascular	1301 S Cliff Ave	Sioux Falls	SD	Active
DSH430016BD	Child	DSH	AVERA MCKENNAN	Neuro Critical Care	1301 S Cliff Ave	Sioux Falls	SD	Active
DSH430016BE	Child	DSH	AVERA MCKENNAN	Neurosurgery	1301 S Cliff Ave	Sioux Falls	SD	Active
DSH430016BF	Child	DSH	AVERA MCKENNAN	Avera Medical Group Neurology	1301 S Cliff Ave	Sioux Falls	SD	Active
DSH430016BG	Child	DSH	AVERA MCKENNAN	Avera Medical Group Dermatology - Marion Rd	2100 S Marion Rd	Sioux Falls	SD	Active
DSH430016BH	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Breast Oncology	1000 E 23rd St	Sioux Falls	SD	Active
DSH430016BJ	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Dermatology - Dawley Farms	1600 S Highline Ave	Sioux Falls	SD	Active
DSH430016BK	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Internal Medicine - Dawley Farms	1600 S Highline Ave	Sioux Falls	SD	Active
DSH430016BL	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Family Practice - Dawley Farms	1600 S Highline Ave	Sioux Falls	SD	Active
DSH430016BM	Child	DSH	AVERA MCKENNAN	Avera Medical Group Orthopedics - Hand Clinic	6100 S Louise Ave	Sioux Falls	SD	Active
DSH430016BN	Child	DSH	AVERA MCKENNAN	Avera Medical Group Obstetrics - Dawley Farms	1600 South Highline Ave	Sioux Falls	SD	Active
DSH430016BP	Child	DSH	AVERA MCKENNAN	Avera Medical Group Pediatrics Dawley Farms - Pediatrics	1600 South Highline Ave	Sioux Falls	SD	Active
DSH430016BQ	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Maternal Fetal Medicine - Dawley Farm	1600 Highline Ave	Sioux Falls	SD	Active
DSH430016BR	Child	DSH	AVERA MCKENNAN	Avera Medical Group - ENT	1417 S Cliff Ave	Sioux Falls	SD	Active
DSH430016BS	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Comprehensive Breast	1000 E 23rd	Sioux Falls	SD	Active
DSH430016BT	Child	DSH	AVERA MCKENNAN	Avera Medical Group - Radiation Oncology	1000 E 23rd	Sioux Falls	SD	Active
DSH430016BU	Child	DSH	AVERA MCKENNAN	Avera Comprehensive Weight Management	6000 W 41st St	Sioux Falls	SD	Active
DSH430016BV	Child	DSH	AVERA MCKENNAN	ED East - Emergency Room	1600 S Highline Ave	Sioux Falls	SD	Active
DSH430016BW	Child	DSH	AVERA MCKENNAN	Avera on Louise - Outpatient Surgery	6100 S Louise Ave	Sioux Falls	SD	Active
DSH430016BX	Child	DSH	AVERA MCKENNAN	Avera Dialysis	4210 West 53rd St	Sioux Falls	SD	Active
DSH430016BY	Child	DSH	AVERA MCKENNAN	Avera Behavioral Health - Partial Hospital Program	4400 W 69th St	Sioux Falls	SD	Active
DSH430016BZ	Child	DSH	AVERA MCKENNAN	Avera Dialysis - Brookings - Renal Therapy	300 22nd Ave	Brookings	SD	Active
DSH430016C	Child	DSH	AVERA MCKENNAN	Avera Medical Group Hematology, Transplant & Cellular Therapy	1000 E 23RD ST	SIOUX FALLS	SD	Active
DSH430016CA	Child	DSH	AVERA MCKENNAN	Avera Dialysis - Milbank - Renal Therapy	301 Flynn Dr	Milbank	SD	Active
DSH430016CB	Child	DSH	AVERA MCKENNAN	Avera Dialysis - Mitchell - Renal Therapy	1900 Grassland Drive	Mitchell	SD	Active
DSH430016CC	Child	DSH	AVERA MCKENNAN	New Hope Dialysis Center - Renal Therapy	310 W SD Hwy 46	Wagner	SD	Active
DSH430016D	Child	DSH	AVERA MCKENNAN	Avera Medical Group Pulmonary & Sleep Medicine	1301 S CLIFF AVE	SIOUX FALLS	SD	Active
DSH430016E	Child	DSH	AVERA MCKENNAN	Avera Nephrology Plaza 2 & 4	911 E 20th St	Sioux Falls	SD	Active
DSH430016F	Child	DSH	AVERA MCKENNAN	Avera Endocrinology & Diabetes	1600 S. Highline Ave	Sioux Falls	SD	Active
DSH430016G	Child	DSH	AVERA MCKENNAN	Avera Therapy	1301 S CLIFF AVE	SIOUX FALLS	SD	Active
DSH430016H	Child	DSH	AVERA MCKENNAN	Avera Medical Group Rheumatology	6100 S Louise Ave	Sioux Falls	SD	Active
DSH430016J	Child	DSH	AVERA MCKENNAN	Avera Medical Group Behavioral Health - Children	4400 W 69TH STREET	SIOUX FALLS	SD	Active
DSH430016K	Child	DSH	AVERA MCKENNAN	Avera Medical Group Behavioral Health - Adult	4400 W 69TH ST	SIOUX FALLS	SD	Active
DSH430016L	Child	DSH	AVERA MCKENNAN	Avera Medical Group Gynecologic Oncology	1000 E 23RD ST	Sioux Falls	SD	Active
DSH430016M	Child	DSH	AVERA MCKENNAN	Avera Medical Group Eye Care	911 East 20th St.	Sioux Falls	SD	Terminated
DSH430016N	Child	DSH	AVERA MCKENNAN	Avera Medical Group Dermatology	6701 S Minnesota Ave	Sioux Falls	SD	Active
DSH430016P	Child	DSH	AVERA MCKENNAN	Avera Liver Disease	1600 S. Highline Ave	Sioux Falls	SD	Active
DSH430016R	Child	DSH	AVERA MCKENNAN HOSPITAL AND UNIVERSITY HEALTH CENTER	Avera Medical Group McHale Institute	3720 W 69th Street # 1	Sioux Falls	SD	Terminated
DSH430016S	Child	DSH	AVERA MCKENNAN	Avera Medical Group McGreevy - 69th and Western	1910 W 69th St	Sioux Falls	SD	Active
DSH430016T	Child	DSH	AVERA MCKENNAN	Avera Medical Group McGreevy - 7th Ave	1200 S 7th Ave	Sioux Falls	SD	Active
DSH430016U	Child	DSH	AVERA MCKENNAN	Avera Medical Group McGreevy - Brandon	1101 E Holly Blvd	Brandon	SD	Active
DSH430016V	Child	DSH	AVERA MCKENNAN	Avera Medical Group McGreevy - Dawley Farm	1035 S HIGHLINE PLACE	SIOUX FALLS	SD	Terminated
DSH430016W	Child	DSH	AVERA MCKENNAN	Avera Medical Group Harrisburg	220 S Cliff Ave	Harrisburg	SD	Active
DSH430016X	Child	DSH	AVERA MCKENNAN	Avera Medical Group Pediatrics - Marion Rd.	2100 S MARION RD	SIOUX FALLS	SD	Active
DSH430016Z	Child	DSH	AVERA MCKENNAN	Avera Medical Group Family Medicine - Cliff Ave.	6215 S CLIFF AVE	Sioux Falls	SD	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Delete	Group Change Request	Avera McKennan 3820 N Potsdam Ave Ste 3 Sioux Falls, SD 57104		4/8/2025 1:53 PM
Addresses	Shipping Address	Insert	Group Change Request		Avera Pharmacy Distribution Center 4101 W Memory Circle, Ste 150 Sioux Falls, SD 57107	4/8/2025 1:53 PM
Details	Last Recertification Date	Update	Recertification	9/6/2023 3:50:40 PM	8/28/2024 11:26:23 AM	8/28/2024 11:26 AM
Addresses	Shipping Address	Insert	Recertification		Avera Medical Group Behavioral Health - Children 4400 W 69th Street Suite 500 Sioux Falls, SD 57108	9/6/2023 3:50 PM
Addresses	Shipping Address	Insert	Recertification		Avera McKennan dba Avera on Louise Inpatient Pharmacy 6100 S Louise Ave Suite B300 Sioux Falls, SD 57108	9/6/2023 3:50 PM
Addresses	Shipping Address	Insert	Recertification		Avera McKennan 3820 N Potsdam Ave Ste 3 Sioux Falls, SD 57104	9/6/2023 3:50 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 10:06:27 AM	9/6/2023 3:50:40 PM	9/6/2023 3:50 PM
Details	Entity Subname	Update	Change Request	Avera Medical Group Psychiatric Medicine	Avera Medical Group Behavioral Health - Children	1/19/2023 9:34 AM
Details	Last Recertification Date	Update	Recertification	9/2/2021 3:55:43 PM	9/14/2022 10:06:27 AM	9/14/2022 10:06 AM
Details	Last Recertification Date	Update	Recertification	8/31/2020 1:52:15 PM	9/2/2021 3:55:43 PM	9/2/2021 3:55 PM
Contacts	Authorizing Official	Update	Change Request	Petersen, Steve Vice President of Pharmacy Avera 6053228313	Goff, Melissa Vice President - Pharmacy Avera 6053228548	5/24/2021 7:02 PM
Contacts	Primary Contact	Update	Profile Change Request	Friesen, Brandy 340b Coordinator Avera 6053228446	Friesen, Brandy Pharmacy Regulatory Analyst Avera 6053228446	4/28/2021 1:48 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 7:11:27 AM	8/31/2020 1:52:15 PM	8/31/2020 1:52 PM
Details	Last Recertification Date	Update	Recertification	9/12/2018 3:59:44 PM	9/5/2019 7:11:27 AM	9/5/2019 7:11 AM
Details	Entity Subname	Update	Recertification	AMG MIDWEST PSYCHIATRY	Avera Medical Group Psychiatric Medicine	9/5/2019 7:11 AM
Addresses	Billing Address	Insert	Recertification		AVERA MCKENNAN HOSPITAL PO Box 5045 Sioux Falls, SD 57117	9/12/2018 3:59 PM
Addresses	Shipping Address	Insert	Recertification		Avera McKennan Hospital 1325 S Cliff Avenue Sioux Falls, SD 57105	9/12/2018 3:59 PM
Addresses	Shipping Address	Insert	Recertification		AVERA DISTRIBUTION CENTER 3301 N 1ST AVE SIOUX FALLS, SD 57104	9/12/2018 3:59 PM
Addresses	Main Address	Update	Recertification	4400 WEST 69TH STREET SUITE 500 SIOUX FALLS, SD 57108	4400 W 69TH STREET STE 500 SIOUX FALLS, SD 57108	9/12/2018 3:59 PM
Addresses	Shipping Address	Delete	Recertification	Avera McKennan Hospital 1325 S Cliff Ave Sioux Falls, SD 57105		9/12/2018 3:59 PM
Details	Last Recertification Date	Update	Recertification	11/16/2017 11:35:25 AM	9/12/2018 3:59:44 PM	9/12/2018 3:59 PM
Details	Entity Subname	Update	Recertification	AVERA MEDICAL GROUP MIDWEST PSYCHIATRIC MEDICINE	AMG MIDWEST PSYCHIATRY	9/12/2018 3:59 PM
Details	Entity Name	Update	Recertification	AVERA MCKENNAN HOSPITAL AND UNIVERSITY HEALTH CENTER	AVERA MCKENNAN	9/5/2018 12:00 PM
Contacts	Authorizing Official	Update	Change Request	Flicek, David Avera McKennan President/CEO Avera McKennan 6053227916	Petersen, Steve Vice President of Pharmacy Avera 6053228313	12/27/2017 2:32 PM
Contacts	Primary Contact	Insert	Recertification		Friesen, Brandy 340b Coordinator Avera 6053228446	11/16/2017 11:35 AM
Details	Last Recertification Date	Update	Recertification	8/25/2016 12:00:00 AM	11/16/2017 11:35:25 AM	11/16/2017 11:35 AM
Contacts	Authorizing Official	Update		Flicek, David Avera McKennan President/CEO 6053227916	Flicek, David Avera McKennan President/CEO Avera McKennan 6053227916	10/12/2017 5:09 PM
Contacts	Authorizing Official	Insert			Flicek, David Avera McKennan President/CEO 6053227916	8/3/2017 11:37 AM
Addresses	Main Address	Insert			4400 WEST 69TH STREET SUITE 500 SIOUX FALLS, SD 57108	8/3/2017 11:37 AM
Addresses	Shipping Address	Insert			Avera McKennan Hospital 1325 S Cliff Ave Sioux Falls, SD 57105	8/3/2017 11:37 AM
Details	Last Recertification Date	Update		8/26/2015 12:00:00 AM	8/25/2016 12:00:00 AM	8/25/2016 3:44 PM
Details	Last Recertification Date	Update		8/12/2014 12:00:00 AM	8/26/2015 12:00:00 AM	8/26/2015 1:40 PM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	8/12/2014 12:00:00 AM	8/12/2014 11:30 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/6/2013 12:00:00 AM	9/6/2013 6:49 AM
Details	Entity Subname	Update		AVERA BEHAVIORAL HEALTH CENTER	AVERA MEDICAL GROUP MIDWEST PSYCHIATRIC MEDICINE	9/6/2013 6:49 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 9:01 AM
Details	Last Recertification Date	Insert				8/5/2010 1:36 PM
Details	Grant Number	Insert				8/5/2010 1:36 PM
Details	340B ID	Insert			DSH430016J	8/5/2010 1:36 PM
Details	Is Authorizing Official EHB Data	Insert				8/5/2010 1:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/5/2010 1:36 PM
Details	Medicare Provider Number	Insert			430016	8/5/2010 1:36 PM
Details	Entity Name	Insert			AVERA MCKENNAN HOSPITAL AND UNIVERSITY HEALTH CENTER	8/5/2010 1:36 PM
Details	Program Code	Insert			DSH	8/5/2010 1:36 PM
Details	Entity Subname	Insert			AVERA BEHAVIORAL HEALTH CENTER	8/5/2010 1:36 PM
Dates	Participating Approval Date	Insert			5/26/2009 12:00:00 AM	8/5/2010 1:36 PM
Details	State	Insert			Active	8/5/2010 1:36 PM
Dates	Registration Date	Insert			5/12/2009 12:00:00 AM	8/5/2010 1:36 PM
Dates	Signed By Date	Insert			3/10/2009 12:00:00 AM	8/5/2010 1:36 PM
Dates	Start Date	Insert			7/1/2009 12:00:00 AM	8/5/2010 1:36 PM
Terminations	Termination Comments	Insert				8/5/2010 1:36 PM
Terminations	Termination Date	Insert				8/5/2010 1:36 PM
Terminations	Termination Effective Date	Insert				8/5/2010 1:36 PM
Terminations	Termination Reason	Insert				8/5/2010 1:36 PM
Details	Comments Public	Insert			10/8/09 UPDATED SUBDIV NAME (WAS AVERA MIDWEST PSYCHIATRIC MEDICINE)	8/5/2010 1:36 PM