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AVERA MCKENNAN HOME INFUSION
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
AVERA MCKENNAN HOME INFUSION
Pharmacy Address
1020 S CLIFF AVE
SIOUX FALLS, SD 57104
Pharmacy Comments
Contract Details
Approval Date
7/9/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/7/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DAVE KAPASKA, REGIONAL PRESIDENT/CEO
(605) 322-7808
Contract Pharmacy Representative
Jerome Kappes, Pharmacy Manager
(605) 322-8316
Signed By Date
7/9/2015
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