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SHOPKO PHARMACY #2076
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
SHOPKO PHARMACY #2076
Pharmacy Address
1601 WEST 41 STREET
SIOUX FALLS, SD 57105
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/11/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
DAVE KAPASKA, REGIONAL PRESIDENT/CEO
(605) 322-7808
Contract Pharmacy Representative
Shopko
Tad Schilke, Director of Rx Merchandising & Marketing
(920) 429-7628
Signed By Date
4/14/2014
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