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WAL-MART PHARMACY 10-1685
DSH430015 AVERA ST. MARY'S
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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
WAL-MART PHARMACY 10-1685
Pharmacy Address
1730 N. GARFIELD RD.
PIERRE, SD 57501
Pharmacy Comments
Contract Details
Approval Date
12/17/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Wagner, CFO
(605) 224-3127 Ext: 3127
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/19/2014
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