Covered Entity Details

SCH430015-00 AVERA ST MARYS (Terminated) - information as of 5/3/2025 11:29:12 PM

Main Details

Name

AVERA ST MARYS

Subdivision Name

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH430015-00

Medicare Provider Number

430015

Additional Details

Current Program Status

Terminated

Registration Date

8/17/2020

Participating Start Date

10/1/2020

Participating Approval Date

8/28/2020

Last Recertification Date

Termination Date
Termination Reason

10/1/2020
Other

Contacts

Authorizing Official

Avera
Steve Petersen, Vice President of Pharmacy
(605) 322-8313

Primary Contact

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

Addresses

Street Address

801 E SIOUX AVENUE
PIERRE, SD 57501

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (1/1/2014) until terminated effective date: (10/1/2014), reinstatement effective date: (10/01/2020).	08/28/2020

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 St. Mary's Hospital
801 E Sioux Ave
Pierre, SD 57501

Shipping Address 2

Avera St. Mary's Campus Pharmacy
100 Mac Ln
Ste 101
Pierre, SD 57501-0000

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Terminate		10/1/2020 12:00:00 AM	9/21/2020 9:03 AM
Details	State	Update	OPA Terminate	Approved	To Be Terminated	9/21/2020 9:03 AM
Terminations	Termination Comments	Update	OPA Terminate		Entity will remain as a DSH	9/21/2020 9:03 AM
Terminations	Termination Date	Update	OPA Terminate		10/1/2020 12:00:00 AM	9/21/2020 9:03 AM
Terminations	Termination Effective Date	Update	OPA Terminate		10/1/2020 12:00:00 AM	9/21/2020 9:03 AM
Terminations	Termination Reason	Update	OPA Terminate		Other	9/21/2020 9:03 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Avera St. Mary's Hospital 801 E Sioux Ave Pierre, SD 57501	8/28/2020 9:33 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Avera St. Mary's Campus Pharmacy 100 Mac Ln Ste 101 Pierre, SD 57501-0000	8/28/2020 9:33 AM
Addresses	Main Address	Update	Hospital Type Change Request	801 E. Sioux Ave Pierre, SD 57501	801 E SIOUX AVENUE PIERRE, SD 57501	8/28/2020 9:33 AM
Contacts	Authorizing Official	Update	Hospital Type Change Request	Wagner, Tom CFO 6052243127-3127	Petersen, Steve Vice President of Pharmacy Avera 6053228313	8/28/2020 9:33 AM
Contacts	Signed By	Update	Hospital Type Change Request	Wagner, Tom CFO 6052243127-3127	Petersen, Steve Vice President of Pharmacy Avera 6053228313	8/28/2020 9:33 AM
Contacts	Primary Contact	Update	Hospital Type Change Request	Petersen, Steve Vice President of Pharmacy Avera 6053228313	Friesen, Brandy 340b Coordinator Avera 6053228446	8/28/2020 9:33 AM
Details	Last Recertification Date	Update	Hospital Type Change Request	8/11/2014 12:00:00 AM		8/28/2020 9:33 AM
Details	Entity Name	Update	Hospital Type Change Request	Avera St. Mary's Hospital	AVERA ST MARYS	8/28/2020 9:33 AM
Dates	Participating Approval Date	Update	Hospital Type Change Request	10/25/2013 12:00:00 AM	8/28/2020 9:33:17 AM	8/28/2020 9:33 AM
Details	State	Update	Hospital Type Change Request	Terminated	Approved	8/28/2020 9:33 AM
Dates	Registration Date	Update	Hospital Type Change Request	10/8/2013 12:00:00 AM	8/17/2020 8:28:36 AM	8/28/2020 9:33 AM
Dates	Signed By Date	Update	Hospital Type Change Request	10/8/2013 12:00:00 AM	8/17/2020 11:22:22 AM	8/28/2020 9:33 AM
Dates	Start Date	Update	Hospital Type Change Request	1/1/2014 12:00:00 AM	10/1/2020 12:00:00 AM	8/28/2020 9:33 AM
Terminations	Termination Comments	Update	Hospital Type Change Request	Registration of entity as a new entity of SCH was approved.		8/28/2020 9:33 AM
Terminations	Termination Date	Update	Hospital Type Change Request	10/1/2014 12:00:00 AM		8/28/2020 9:33 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request	10/1/2014 12:00:00 AM		8/28/2020 9:33 AM
Terminations	Termination Reason	Update	Hospital Type Change Request	Change of covered entity type		8/28/2020 9:33 AM
Details	Comments Public	Insert	Hospital Type Change Request		Participating from effective date: (1/1/2014) until terminated effective date: (10/1/2014), reinstatement effective date: (10/01/2020).	8/28/2020 8:48 AM
Addresses	Main Address	Update		801 E SIOUX AVENUE PIERRE, SD 57501	801 E. Sioux Ave Pierre, SD 57501	8/12/2020 11:26 AM
Contacts	Primary Contact	Update		Petersen, Steve Vice President of Pharmacy Avera 6053228313	Petersen, Steve Vice President of Pharmacy Avera 6053228313	8/12/2020 11:26 AM
Contacts	Authorizing Official	Update		Wagner, Tom CFO 6052243127-3127	Wagner, Tom CFO 6052243127-3127	8/12/2020 11:26 AM
Contacts	Signed By	Update		Wagner, Tom CFO 6052243127-3127	Wagner, Tom CFO 6052243127-3127	8/12/2020 11:26 AM
Addresses	Main Address	Update	Hospital Type Change Request	801 E. Sioux Ave Pierre, SD 57501	801 E SIOUX AVENUE PIERRE, SD 57501	8/5/2020 10:44 AM
Contacts	Primary Contact	Update	Change Request	Petersen, Steve Vice President of Pharmacy Avera McKennan 6053228313	Petersen, Steve Vice President of Pharmacy Avera 6053228313	12/22/2017 10:56 AM
Contacts	Primary Contact	Update		Petersen, Steve Vice President of Pharmacy 6053228313	Petersen, Steve Vice President of Pharmacy Avera McKennan 6053228313	10/9/2017 11:19 AM
Contacts	Primary Contact	Insert			Petersen, Steve Vice President of Pharmacy 6053228313	8/3/2017 11:37 AM
Contacts	Authorizing Official	Insert			Wagner, Tom CFO 6052243127-3127	8/24/2016 12:21 PM
Contacts	Signed By	Insert			Wagner, Tom CFO 6052243127-3127	8/24/2016 12:21 PM
Addresses	Main Address	Update		801 EAST DAKOTA Pierre, SD 57501	801 E. Sioux Ave Pierre, SD 57501	9/16/2014 11:53 AM
Addresses	Main Address	Insert			801 EAST DAKOTA Pierre, SD 57501	9/16/2014 11:53 AM
Details	State	Update		Active	Terminated	9/16/2014 11:52 AM
Terminations	Termination Comments	Update			Registration of entity as a new entity of SCH was approved.	9/16/2014 11:52 AM
Terminations	Termination Date	Update			10/1/2014 12:00:00 AM	9/16/2014 11:52 AM
Terminations	Termination Effective Date	Update			10/1/2014 12:00:00 AM	9/16/2014 11:52 AM
Terminations	Termination Reason	Update			Change of covered entity type	9/16/2014 11:52 AM
Details	Last Recertification Date	Update			8/11/2014 12:00:00 AM	8/11/2014 2:58 PM
Details	Entity Name	Update		ST. MARY'S HEALTHCARE CENTER	Avera St. Mary's Hospital	11/1/2013 10:08 AM
Dates	Participating Approval Date	Update			10/25/2013 12:00:00 AM	10/25/2013 2:44 PM
Details	State	Update		Pending	Active	10/25/2013 2:44 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	10/25/2013 2:44 PM
Details	340B ID	Update		ONLINE_REG	SCH430015-00	10/25/2013 1:38 PM
Details	Entity Name	Update		Avera St. Mary's Hospital	ST. MARY'S HEALTHCARE CENTER	10/25/2013 1:38 PM
Details	Entity Subname	Update		Avera St. Mary's Hospital		10/25/2013 1:38 PM
Details	Last Recertification Date	Insert				10/8/2013 2:16 PM
Details	Grant Number	Insert				10/8/2013 2:16 PM
Details	340B ID	Insert			ONLINE_REG	10/8/2013 2:16 PM
Details	Is Authorizing Official EHB Data	Insert				10/8/2013 2:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/8/2013 2:16 PM
Details	Medicare Provider Number	Insert			430015	10/8/2013 2:16 PM
Details	Entity Name	Insert			Avera St. Mary's Hospital	10/8/2013 2:16 PM
Details	Program Code	Insert			SCH	10/8/2013 2:16 PM
Details	Entity Subname	Insert			Avera St. Mary's Hospital	10/8/2013 2:16 PM
Dates	Participating Approval Date	Insert				10/8/2013 2:16 PM
Details	State	Insert			Pending	10/8/2013 2:16 PM
Dates	Registration Date	Insert			10/8/2013 12:00:00 AM	10/8/2013 2:16 PM
Dates	Signed By Date	Insert			10/8/2013 12:00:00 AM	10/8/2013 2:16 PM
Dates	Start Date	Insert				10/8/2013 2:16 PM
Terminations	Termination Comments	Insert				10/8/2013 2:16 PM
Terminations	Termination Date	Insert				10/8/2013 2:16 PM
Terminations	Termination Effective Date	Insert				10/8/2013 2:16 PM
Terminations	Termination Reason	Insert				10/8/2013 2:16 PM