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DSH430016BT AVERA MCKENNAN (Active)
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Main Details
Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group - Radiation Oncology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH430016BT
Medicare Provider Number
430016
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
4/13/2023
Participating Start Date
5/31/2023
Participating Approval Date
5/4/2023
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
1000 E 23rd
Suite 100
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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