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AVERA 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
AVERA STATE STREET PHARMACY
Pharmacy Address
AVERA ST. LUKE'S
105 S STATE ST STE 101
ABERDEEN, SD 57401-4501
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Avera
Darrel Mutchler, Director of Retail Pharmacy
(605) 322-8331
Signed By Date
7/15/2022
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