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DSH430016AX AVERA MCKENNAN (Active)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
McKennan Outpatient Infusion
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016AX
Medicare Provider Number
430016
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/14/2019
Participating Start Date
1/1/2020
Participating Approval Date
10/28/2019
Last Recertification Date
8/28/2024
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
1417 S Cliff Avenue
Avera Plaza 1
Floor 5
Sioux Falls, SD 57105
Billing Address
Avera McKennan
PO Box 5045
Sioux Falls, SD 57117
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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