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AVERA SPECIALTY PHARMACY
DSH430077 Monument Health Rapid City Hospital
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Covered Entity Details
Entity Name
Monument Health Rapid City Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430077
Entity Address
353 FAIRMONT BLVD
RAPID CITY, SD 57701
Medicare Provider Number
430077
Participating Start Date
4/1/2004
Last Recertification Date
9/12/2024
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
1/18/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ruta Paulette Davidson, President & CEO
(605) 755-9130
Contract Pharmacy Representative
Avera McKennan
David Flicek, Avera McKennan President/CEO
(605) 322-7916
Signed By Date
1/18/2023
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