340B Drug Pricing Program Database
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Walmart Pharmacy 10-7611
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
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
1/16/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Walmart
Tisha Campbell, Director of Contracting
(949) 872-4138
Signed By Date
1/16/2024
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