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DSH430016H AVERA MCKENNAN (Active)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Rheumatology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016H
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
8/26/2024
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
6100 S Louise Ave
Suite 1130
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
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3/27/12 UPDATED SUBDIV NAME (WAS AVERA RHEUMATOLOGY); 05/05/11 UPDATED ADDR.(WAS 1100 EAST 21ST STREET SUITE 300)
03/27/2012
05/05/11 UPDATED ADDR.(WAS 1100 EAST 21ST STREET SUITE 300)
05/05/2011
April 2025
April 2025
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