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HY-VEE PHARMACY FULFILLMENT CENTER 4016
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
HY-VEE PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
10/28/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/16/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DAVE KAPASKA, REGIONAL PRESIDENT/CEO
(605) 322-7808
Contract Pharmacy Representative
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
10/10/2013
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