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SCH430012-02 Sacred Heart Health Services DBA Avera Sacred Heart Hospital (Terminated)
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Main Details
Name
Sacred Heart Health Services DBA Avera Sacred Heart Hospital
Subdivision Name
Avera Medical Group Crofton
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH430012-02
Medicare Provider Number
430012
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
9/23/2010
Participating Start Date
7/1/2015
Participating Approval Date
9/27/2010
Last Recertification Date
11/21/2017
Termination Date
Termination Reason
1/1/2018
Hospital Outpatient facility no longer eligible
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
203 West Main
Crofton, NE 68730
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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5/29/15 Previously participated starting 9/27/2010, terminated 4/1/12, reinstated effective 7/1/15 based on registration submitted in April 2015
05/29/2015
April 2025
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