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AVERA SPECIALTY PHARMACY
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
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
1/13/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Wagner, CFO
(605) 224-3127 Ext: 3127
Contract Pharmacy Representative
Avera Specialty Pharmacy
Brian Lounsbery, Pharmacy Manager
(605) 322-8360
Signed By Date
1/13/2015
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