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AVERA SPECIALTY PHARMACY
DSH430016H AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Rheumatology
Type
Disproportionate Share Hospital
340B ID
DSH430016H
Entity Address
6100 S Louise Ave
Suite 1130
Sioux Falls, SD 57108
Medicare Provider Number
430016
Outpatient Facility Provider Number
Participating Start Date
7/1/2009
Last Recertification Date
8/26/2024
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
7/7/2009
Contract Begin Date
7/7/2009
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
6/22/2009
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