Contract Pharmacy Details

AVERA ST. MARY'S CAMPUS PHARM
DSH430016 AVERA MCKENNAN

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

AVERA ST. MARY'S CAMPUS PHARM

Pharmacy Address

AVERA ST. MARY'S
100 MAC LN STE 101
PIERRE, SD 57501-3393

Pharmacy Comments

Contract Details

Approval Date

1/7/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Steve Petersen, Vice President of Pharmacy
(605) 322-8313

Contract Pharmacy Representative

Avera
Darrel Mutchler, Director of Retail Pharmacy
(605) 322-8331

Signed By Date

1/7/2020

340B Drug Pricing Program Database