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AVERA MCKENNAN HOME INFUSION
DSH430016K AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Behavioral Health - Adult
Type
Disproportionate Share Hospital
340B ID
DSH430016K
Entity Address
4400 W 69TH ST
STE 1500
SIOUX FALLS, SD 57108
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 HOME INFUSION
Pharmacy Address
1020 S CLIFF AVE
SIOUX FALLS, SD 57104
Pharmacy Comments
Contract Details
Approval Date
11/24/2009
Contract Begin Date
11/24/2009
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
STEVE PETERSEN, DIRECTOR OF PHARMACY
(605) 322-8313
Signed By Date
11/12/2009
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