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DSH430016L AVERA MCKENNAN (Active)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Gynecologic Oncology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016L
Medicare Provider Number
430016
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/31/2012
Participating Start Date
4/1/2012
Participating Approval Date
3/28/2012
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
1000 E 23RD ST
STE 350
Sioux Falls, SD 57105
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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2/2/12 Contacted AO & CP for supporting docs
02/02/2012
April 2025
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