Contract Pharmacy Details

WAL-MART CENTRAL FILL 10-2670
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

WAL-MART CENTRAL FILL 10-2670

Pharmacy Address

608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386

Pharmacy Comments

Contract Details

Approval Date

1/8/2020

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

Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498

Signed By Date

1/8/2020

340B Drug Pricing Program Database