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AVERA ST. MARY'S CAMPUS PHARM
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 ST. MARY'S CAMPUS PHARM
Pharmacy Address
AVERA ST. MARY'S
100 MAC LN STE 101
PIERRE, SD 57501-3393
Pharmacy Comments
Contract Details
Approval Date
11/3/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/17/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Todd Forkel, CEO
(605) 622-5125
Contract Pharmacy Representative
Avera
Darrel Mutchler, Director of Retail Pharmacy
(605) 322-8331
Signed By Date
11/3/2016
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