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AVERA MCKENNAN CAMPUS PHARMACY
DSH430016F AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Avera Endocrinology & Diabetes
Type
Disproportionate Share Hospital
340B ID
DSH430016F
Entity Address
1600 S. Highline Ave
Ste 300
Sioux Falls, SD 57110
Medicare Provider Number
430016
Outpatient Facility Provider Number
Participating Start Date
7/1/2009
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
AVERA MCKENNAN CAMPUS PHARMACY
Pharmacy Address
1325 S CLIFF AVE STE CP
SIOUX FALLS, SD 57105-1008
Pharmacy Comments
5/5/11 UPDATED ADDR (WAS 800 EAST 21ST STREET, SUITE CP)
Contract Details
Approval Date
10/17/2009
Contract Begin Date
10/17/2009
Carve-In Effective Date
Contract Comments
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
9/15/2009
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