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MAIN STREET PHARMACY I, CORP.
DSH430016 AVERA MCKENNAN
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Covered Entity Details
Entity Name
AVERA MCKENNAN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430016
Entity Address
1325 S. CLIFF AVE.
SIOUX FALLS, SD 57105
Medicare Provider Number
430016
Participating Start Date
9/18/2008
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
MAIN STREET PHARMACY I, CORP.
Pharmacy Address
DBA NORM'S THRIFTY WHITE PHARMACY
389 S. MAIN ST.
PO BOX 120
FREEMAN, SD 57029-0120
Pharmacy Comments
Contract Details
Approval Date
10/12/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Flicek, Avera McKennan President/CEO
(605) 322-7916
Contract Pharmacy Representative
Norm's Thrifty White
Norm Kaufman, Owner
(605) 925-7029
Signed By Date
10/12/2017
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