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LEWIS FAMILY DRUG #67
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
LEWIS FAMILY DRUG #67
Pharmacy Address
LEWIS FAMILY DRUG LLC
420 2ND AVE
SIBLEY, IA 51249-1205
Pharmacy Comments
Contract Details
Approval Date
4/15/2023
Contract Begin Date
4/25/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Lewis Drug
Scott Cross, EVP
(605) 367-2800
Signed By Date
4/15/2023
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