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AVERA MCKENNAN CAMPUS PHARMACY
DSH430016J AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Avera Medical Group Behavioral Health - Children
Type
Disproportionate Share Hospital
340B ID
DSH430016J
Entity Address
4400 W 69TH STREET
STE 500
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 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
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
STEVE PETERSEN, DIRECTOR OF PHARMACY
(605) 322-8313
Signed By Date
6/22/2009
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