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DSH430016BK AVERA MCKENNAN (Active)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group - Internal Medicine - Dawley Farms
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016BK
Medicare Provider Number
430016
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/17/2022
Participating Start Date
1/1/2023
Participating Approval Date
11/9/2022
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
1600 S Highline Ave
210
Sioux Falls, SD 57110
Billing Address
Avera McKennan
PO Box 5045
Sioux Falls, SD 57117
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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