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K MART PHARMACY
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
K MART PHARMACY
Pharmacy Address
3020 W 12TH STREET
SIOUX FALLS, SD 57104
Pharmacy Comments
Contract Details
Approval Date
4/11/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/21/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
DAVE KAPASKA, REGIONAL PRESIDENT/CEO
(605) 322-7808
Contract Pharmacy Representative
Ryan Castle, Director, Managed Care Services
(847) 286-5153
Signed By Date
4/11/2014
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