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AVERA SPECIALTY PHARMACY
CAH431315-00 WAGNER COMMUNITY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WAGNER COMMUNITY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH431315-00
Entity Address
513 3RD ST SW
WAGNER, SD 57380
Medicare Provider Number
431315
Participating Start Date
8/18/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
AVERA SPECIALTY PHARMACY
Pharmacy Address
500 E 56TH ST N STE 3150
SIOUX FALLS, SD 57104
Pharmacy Comments
5/4/11 UPDATED NAME AND ADDR (WAS AVERA DOCTORS PLAZA 2 PHARMACY, 1100 EAST 21ST STREET, SUITE 200)
Contract Details
Approval Date
1/11/2023
Contract Begin Date
1/17/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRYAN SLABA, CEO
(605) 384-3611 Ext: 284
Contract Pharmacy Representative
Avera McKennan
David Flicek, Avera McKennan President/CEO
(605) 322-7916
Signed By Date
1/11/2023
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