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AVERA LONG-TERM CARE 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 LONG-TERM CARE PHARMACY
Pharmacy Address
AVERA MCKENNAN
4101 W MEMORY CIR STE 120
SIOUX FALLS, SD 57107
Pharmacy Comments
Contract Details
Approval Date
1/13/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Avera
Ronald Place, CEO
(605) 322-7903
Signed By Date
1/13/2025
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