340B Drug Pricing Program Database
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DSH430016M AVERA MCKENNAN (Terminated)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Eye Care
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016M
Medicare Provider Number
430016
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/31/2012
Participating Start Date
4/1/2012
Participating Approval Date
3/28/2012
Last Recertification Date
9/5/2019
Termination Date
Termination Reason
7/1/2020
Business decision by the Covered Entity
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
911 East 20th St.
Suite 101
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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