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WAL-MART PHARMACY 10-2990
CAH431340-00 AVERA QUEEN OF PEACE
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Covered Entity Details
Entity Name
AVERA QUEEN OF PEACE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH431340-00
Entity Address
525 North Foster
Mitchell, SD 57301
Medicare Provider Number
431340
Participating Start Date
4/5/2023
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2990
Pharmacy Address
1101 EAST SPRUCE STREET
MITCHELL, SD 57301
Pharmacy Comments
Contract Details
Approval Date
4/5/2023
Contract Begin Date
4/5/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/5/2023
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