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AVERA LONG-TERM CARE PHARMACY
CAH161351-00 Avera Holy Family Health
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Covered Entity Details
Entity Name
Avera Holy Family Health
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161351-00
Entity Address
826 N 8TH ST
ESTHERVILLE, IA 51334
Medicare Provider Number
161351
Participating Start Date
9/30/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
AVERA LONG-TERM CARE PHARMACY
Pharmacy Address
AVERA MCKENNAN
4101 W MEMORY CIR STE 120
SIOUX FALLS, SD 57107
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/17/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shannon Adams, CFO
(712) 362-2631
Contract Pharmacy Representative
Mark Gerdes, Pharmacy Manager
(605) 322-1447
Signed By Date
10/14/2015
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