Contract Pharmacy Details

VILAS PHARMACY
DSH430015 AVERA ST. MARY'S

Covered Entity Details

Entity Name

AVERA ST. MARY'S

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH430015

Entity Address

801 E SIOUX
PIERRE, SD 57501

Medicare Provider Number

430015

Participating Start Date

10/1/2014

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

VILAS PHARMACY

Pharmacy Address

120 COMMERCIAL SE
PO BOX 419
HIGHMORE, SD 57345

Pharmacy Comments

Contract Details

Approval Date

10/10/2017

Contract Begin Date

1/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/3/2020
Ownership change

Contacts

Covered Entity Signing Official

Todd Forkel, CEO
(605) 622-5125

Contract Pharmacy Representative

Vilas of Highmore
James Stephens, President/Owner
(605) 224-4538

Signed By Date

10/10/2017

340B Drug Pricing Program Database