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PREMIER PHARMACY SERVICES
DSH430016 AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430016
Entity Address
1325 S. CLIFF AVE.
SIOUX FALLS, SD 57105
Medicare Provider Number
430016
Participating Start Date
9/18/2008
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
PREMIER PHARMACY SERVICES
Pharmacy Address
410 CLOVERLEAF DR
BALDWIN PARK, CA 91706
Pharmacy Comments
Contract Details
Approval Date
7/15/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/29/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steve Petersen, Vice President of Pharmacy
(605) 322-8313
Contract Pharmacy Representative
Good Health, Inc
Todd Weber, Director, Government Programs & Strategic Initiatives
(203) 212-4717
Signed By Date
7/15/2018
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