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VILAS
DSH430015 AVERA ST. MARY'S
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Covered Entity Details
Entity Name
AVERA ST. MARY'S
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430015
Entity Address
801 E SIOUX
PIERRE, SD 57501
Medicare Provider Number
430015
Participating Start Date
10/1/2014
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
VILAS
Pharmacy Address
DAKOTA PHARMS, LLC
120 COMMERCIAL AVE SE
HIGHMORE, SD 57345
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/10/2020
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
Custer Community Pharmacy
Dillon Kjerstad, Co-owner
(605) 859-2833
Signed By Date
4/13/2020
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