Contract Pharmacy Details

SHANE'S PHARMACY
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

SHANE'S PHARMACY

Pharmacy Address

213 E HUSTAN AVE
STE A
FORT PIERRE, SD 57532-5103

Pharmacy Comments

Contract Details

Approval Date

7/15/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Todd Forkel, CEO
(605) 622-5125

Contract Pharmacy Representative

Shane Clarambeau, Owner
(605) 223-9200

Signed By Date

7/15/2017