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STATE STREET PHARMACY
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
STATE STREET PHARMACY
Pharmacy Address
105 S STATE ST STE 111
ABERDEEN, SD 57401-4502
Pharmacy Comments
Contract Details
Approval Date
4/7/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/9/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Steve Petersen, Vice President of Pharmacy
(605) 322-8313
Contract Pharmacy Representative
State Street Pharmacy
Dave Taffe, Owner
(605) 225-1945
Signed By Date
4/7/2020
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