Contract Pharmacy Details

VILAS PHARMACY OF GETTSBURG
DSH430015 AVERA ST. MARY'S

Covered Entity Details

Entity Name

AVERA ST. MARY'S

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH430015

Entity Address

801 E SIOUX
PIERRE, SD 57501

Medicare Provider Number

430015

Participating Start Date

10/1/2014

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

VILAS PHARMACY OF GETTSBURG

Pharmacy Address

103 E COMMERCIAL AVE
GETTYSBURG, SD 57442-1101

Pharmacy Comments

Contract Details

Approval Date

12/17/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/3/2020
Ownership change

Contacts

Covered Entity Signing Official

Tom Wagner, CFO
(605) 224-3127 Ext: 3127

Contract Pharmacy Representative

Jim Stephens, Owner
(605) 765-9458

Signed By Date

9/19/2014