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AVERA SPECIALTY PHARMACY
DSH430016A AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Internal Medicine
Type
Disproportionate Share Hospital
340B ID
DSH430016A
Entity Address
1301 S CLIFF AVE
STE 400
SIOUX FALLS, SD 57105
Medicare Provider Number
430016
Outpatient Facility Provider Number
Participating Start Date
1/1/2009
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
AVERA SPECIALTY PHARMACY
Pharmacy Address
500 E 56TH ST N STE 3150
SIOUX FALLS, SD 57104
Pharmacy Comments
5/4/11 UPDATED NAME AND ADDR (WAS AVERA DOCTORS PLAZA 2 PHARMACY, 1100 EAST 21ST STREET, SUITE 200)
Contract Details
Approval Date
3/21/2009
Contract Begin Date
3/21/2009
Carve-In Effective Date
Contract Comments
03/20/2009 - TERMINATED PREVIOUS CONTRACT BECAUSE ON INPUT ERROR (ON 03/04/2009) FOR D.B.A. NAME AND ADDRESS OF PHARMACY.
Contract Termination Date
Termination Reason
9/14/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
2/27/2009
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