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LEWIS DRUG #9
DSH430016 AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430016
Entity Address
1325 S. CLIFF AVE.
SIOUX FALLS, SD 57105
Medicare Provider Number
430016
Participating Start Date
9/18/2008
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
LEWIS DRUG #9
Pharmacy Address
115 SPLITROCK BLVD
PO BOX 527
BRANDON, SD 57005
Pharmacy Comments
Contract Details
Approval Date
3/9/2011
Contract Begin Date
3/9/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
2/16/2011
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