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SCH430015-00 AVERA ST MARYS (Terminated)
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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
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Participating from effective date: (1/1/2014) until terminated effective date: (10/1/2014), reinstatement effective date: (10/01/2020).
08/28/2020
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