Covered Entity Details

DSH350015DL SANFORD BISMARCK (Active) - information as of 4/24/2025 11:14:04 PM

Main Details

Name

SANFORD BISMARCK

Subdivision Name

Sanford Watford City Childrens Outreach - Sanford Watford City Childrens Outreach

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH350015DL

Medicare Provider Number

350015

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/25/2024

Last Recertification Date

Contacts

Authorizing Official

Sanford Bismarck
Leigh Ann Thompson, Chief Financial Officer
(701) 323-6720

Primary Contact

Sanford Bismarck
John Savageau, Director - Pharmacy
(701) 323-6186

Addresses

Street Address

709 4th Ave NE Suite 1
Watford City, ND 58854

Billing Address

Sanford Bismarck
300 North 7th St
Bismarck, ND 58501

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
ND	1456048,1458812,1458769,1461466	1477631745,1538245634,1598185597,1669555744,1720075377,1811941172,1669524351

Shipping Addresses

Shipping Address 1

Sanford Bismarck
300 North 7th St
Bismarck, ND 58501

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH350015A	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Hospice Services	910 18TH ST NW	MANDAN	ND	Active
DSH350015AA	Child	DSH	SANFORD BISMARCK	SANFORD Southridge Walk-in Clinic	565 South 7th Street	BISMARCK	ND	Active
DSH350015AB	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Allergy Clinic	701 E Rosser Ave	BISMARCK	ND	Active
DSH350015AC	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Downtown Nephrology	209 N 7 ST	BISMARCK	ND	Active
DSH350015AD	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Downtown Internal Medicine Clinic	515 E Broadway Ave	BISMARCK	ND	Terminated
DSH350015AE	Child	DSH	SANFORD BISMARCK	Sanford Bismarck / Downtown Family Medicine Clinic	209 N 7th St	Bismarck	ND	Active
DSH350015AF	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / 7th & Thayer Podiatry Clinic	225 N 7TH ST	BISMARCK	ND	Active
DSH350015AG	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Plastic Surgery 7th & Thayer Clinic	225 N 7TH ST	BISMARCK	ND	Terminated
DSH350015AH	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK Orthopedics	225 N 7TH ST	BISMARCK	ND	Active
DSH350015AJ	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK CANCER	701 East Rosser Ave	Bismarck	ND	Active
DSH350015AK	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Podiatry Clinic	222 N 7TH ST	BISMARCK	ND	Terminated
DSH350015AL	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Physiatry Clinic	222 N 7TH ST	BISMARCK	ND	Terminated
DSH350015AM	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / General Surgery Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AN	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Internal Medicine	515 E Broadway Ave	BISMARCK	ND	Active
DSH350015AP	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Cardiovascular Surgery Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AQ	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Obstetrics & Gynecology	414 N 7TH ST	BISMARCK	ND	Active
DSH350015AR	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Children's Oncology Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AS	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Neurosurgery Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AT	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Radiology Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AU	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Pulmonology Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AV	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Endocrinology Clinic	4535 Northern Sky Drive	BISMARCK	ND	Active
DSH350015AW	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Neurology Clinic	4535 Northern Sky Drive	BISMARCK	ND	Active
DSH350015AX	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Urology Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015AY	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Rheumatology Clinic	4535 Northern Sky Drive	BISMARCK	ND	Active
DSH350015AZ	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Gastroenterology Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015B	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Home Care	910 18TH ST NW	MANDAN	ND	Active
DSH350015BA	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK PLASTIC SURGERY CLINIC	222 N 7TH ST	BISMARCK	ND	Active
DSH350015BB	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Children's Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015BC	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK CHILDREN'S WALK IN CLINIC	222 N 7TH ST.	BISMARCK	ND	Terminated
DSH350015BD	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Seventh & Thayer Radiology Clinic	225 N 7TH ST	BISMARCK	ND	Active
DSH350015BE	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Dermatology	2830 N. Washington Street	Bismarck	ND	Active
DSH350015BF	Child	DSH	SANFORD BISMARCK	Sanford Bismarck / Downtown Family Medicine Clinic	225 N 7th St	Bismarck	ND	Terminated
DSH350015BG	Child	DSH	SANFORD BISMARCK	Sanford Bismarck / Downtown Dermatology	715 E Broadway Ave	Bismarck	ND	Terminated
DSH350015BH	Child	DSH	SANFORD BISMARCK	Sanford Bismarck / MRI Center	720 E Rosser Ave	Bismarck	ND	Active
DSH350015BJ	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK SPORTS MEDICINE	225 N 7th St	BISMARCK	ND	Active
DSH350015BK	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK PALLATIVE CARE	300 N 7TH ST	BISMARCK	ND	Active
DSH350015BL	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK FAMILY MEDICINE STATE STREET CLINIC	3318 N 14TH ST	BISMARCK	ND	Active
DSH350015BM	Child	DSH	SANFORD BISMARCK	SANFORD - Southridge Radiology Clinic	565 South 7th street	BISMARCK	ND	Active
DSH350015BN	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Surgical Services	414 N 7th St	BISMARCK	ND	Active
DSH350015BP	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Bismarck Diabetes Care at Mandan North	910 18th St NW	Mandan	ND	Terminated
DSH350015BQ	Child	DSH	SANFORD BISMARCK	Sanford Occupational Therapy	1800 East Interstate Ave	Bismarck	ND	Active
DSH350015BR	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Sanford Pulmonology at Mandan North	910 18th St NW	Mandan	ND	Active
DSH350015BS	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Hand Therapy	225 N 7th St	Bismarck	ND	Active
DSH350015BT	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Sanford Speech Therapy	1800 E Interstate Ave	Bismarck	ND	Active
DSH350015BU	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Diabetes Care at Sanford Family Practice South	1040 Tacoma Ave	Bismarck	ND	Terminated
DSH350015BV	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Sanford Pulmonology at Mandan East	102 Mandan Ave	Mandan	ND	Active
DSH350015BW	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Sanford Outpatient Physical Therapy	1800 E Interstate Ave Clinic	Bismarck	ND	Active
DSH350015BX	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Sanford Family Wellness Physical Therapy	2700 46th Ave SE	Mandan	ND	Active
DSH350015BY	Child	DSH	SANFORD BISMARCK	Sanford Bismarck - Sanford Power Physical Therapy	3451 N 14th St Suite C	Bismarck	ND	Active
DSH350015BZ	Child	DSH	SANFORD BISMARCK	Sanford Children's Therapies - Sanford Children's Therapies	809 W Interstate Ave	Bismarck	ND	Active
DSH350015C	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Infusion Center	300 N 7TH ST	BISMARCK	ND	ToBeTerminated
DSH350015CA	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Jamestown Dialysis - Sanford Bismarck Jamestown Dialysis	300 2nd Ave NE	Jamestown	ND	Active
DSH350015CB	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Tom and Francis Leach Dialysis - Sanford Bismarck Tom and Francis Leach Dialysis	209 N 7th St	Bismarck	ND	Active
DSH350015CC	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Fort Yates Dialysis - Sanford Bismarck Fort Yates Dialysis	10 N River Road	Fort Yates	ND	Active
DSH350015CD	Child	DSH	SANFORD BISMARCK	Sanford Surgery Center Thayer - Sanford Surgery Center Thayer	225 N 7th Street	Bismarck	ND	Active
DSH350015CE	Child	DSH	SANFORD BISMARCK	Sanford East Interstate Avenue Pediatrics - Sanford East Interstate Avenue Pediatrics	1800 E Interstate Ave	Bismarck	ND	Active
DSH350015CF	Child	DSH	SANFORD BISMARCK	Sanford Women's Mental Health Clinic - Sanford Women's Mental Health Clinic	414 N 7th St	Bismarck	ND	Active
DSH350015CG	Child	DSH	SANFORD BISMARCK	Sanford Pain Management Psychology - Sanford Pain Management Psychology	414 N 7th St	Bismarck	ND	Active
DSH350015CH	Child	DSH	SANFORD BISMARCK	Sanford Neuropsychology Clinic - Sanford Neuropsychology Clinic	4535 Northern Sky Drive	Bismarck	ND	Active
DSH350015CJ	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Home Dialysis - Sanford Bismarck Home Dialysis	209 N 7th St	Bismarck	ND	Active
DSH350015CK	Child	DSH	SANFORD BISMARCK	Sanford Jamestown Home Dialysis - Sanford Jamestown Home Dialysis	300 2 Ave NE	Jamestown	ND	Active
DSH350015CL	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Infusion Center	701 East Rosser Ave	Bismarck	ND	Active
DSH350015CM	Child	DSH	SANFORD BISMARCK	Sanford Pulmonary Function - Sanford Pulmonary Function	222 North Seventh Street	Bismarck	ND	Active
DSH350015CN	Child	DSH	SANFORD BISMARCK	Sanford Neurodiagnostics center - Sanford Neurodiagnostics center	222 N 7th St	Bismarck	ND	Active
DSH350015CP	Child	DSH	SANFORD BISMARCK	Sanford Childrens Campus Building C Clinic - Sanford Childrens Campus Building C Clinic	809 W interstate Avenue	Bismarck	ND	Active
DSH350015CQ	Child	DSH	SANFORD BISMARCK	Sanford Childrens Campus Building B Clinic - Sanford Childrens Campus Building B Clinic	801 W interstate Ave	Bismarck	ND	Active
DSH350015CR	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Northern Sky Radiology Clinic - Sanford Bismarck Northern Sky Radiology Clinic	4535 Northern Sky Drive	Bismarck	ND	Active
DSH350015CS	Child	DSH	SANFORD BISMARCK	Sanford Broadway Same Day Surgery Center - Sanford Broadway Same Day Surgery Center	715 East Broadway	Bismarck	ND	Active
DSH350015CT	Child	DSH	SANFORD BISMARCK	Sanford west Dickinson Family Medicine Clinic - Sanford west Dickinson Family Medicine Clinic	2615 Fairway Street	Dickinson	ND	Active
DSH350015CU	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Walk in Clinic - Sanford West Dickinson Walk in Clinic	2615 Fairway Street	Dickinson	ND	Active
DSH350015CV	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Childrens Clinic - Sanford West Dickinson Childrens Clinic	2615 Fairway Street	Dickinson	ND	Active
DSH350015CW	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson OB/GYN Clinic - Sanford West Dickinson OB/GYN Clinic	2615 Fairway Street	Dickinson	ND	Active
DSH350015CX	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Orthopedics - Sanford West Dickinson Orthopedics	2615 Fairway Street	Dickinson	ND	Active
DSH350015CY	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Infusion Clinic - Sanford West Dickinson Infusion Clinic	2615 Fairway Street	Dickinson	ND	Active
DSH350015CZ	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Radiology - Sanford West Dickinson Radiology	2615 Fairway Street	Dickinson	ND	Active
DSH350015D	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Neonatology	222 N 7TH ST	BISMARCK	ND	Active
DSH350015DA	Child	DSH	SANFORD BISMARCK	Sanford Minot Highway 2 Physical Therapy Clinic - Sanford Minot Highway 2 Physical Therapy Clinic	801 21st Ave SE	Minot	ND	Active
DSH350015DB	Child	DSH	SANFORD BISMARCK	Sanford Minot Highway 2 Family Medicine Clinic - Sanford Minot Highway 2 Family Medicine Clinic	801 21st Ave Se	Minot	ND	Active
DSH350015DC	Child	DSH	SANFORD BISMARCK	Sanford Minot Highway 2 Walk In Clinic - Sanford Minot Highway 2 Walk In Clinic	801 21st ave SE	Minot	ND	Active
DSH350015DD	Child	DSH	SANFORD BISMARCK	Sanford Minot Highway 2 Radiology - Sanford Minot Highway 2 Radiology	801 21st ave SE	Minot	ND	Active
DSH350015DE	Child	DSH	SANFORD BISMARCK	Sanford Minot NW Family Medicine - Sanford Minot NW Family Medicine	1500 21st Ave NW	Minot	ND	Active
DSH350015DF	Child	DSH	SANFORD BISMARCK	Sanford Minot NW Radiology - Sanford Minot NW Radiology	1500 21st Ave NW	MInot	ND	Active
DSH350015DG	Child	DSH	SANFORD BISMARCK	East Dickinson Internal Medicine - East Dickinson Internal Medicine	33 9th st west	Dickinson	ND	Active
DSH350015DH	Child	DSH	SANFORD BISMARCK	Sanford East Dickinson Family Medicine - Sanford East Dickinson Family Medicine	33 9th St. west	Dickinson	ND	Active
DSH350015DJ	Child	DSH	SANFORD BISMARCK	Sanford East Dickinson Radiology - Sanford East Dickinson Radiology	33 9th street west	Dickinson	ND	Active
DSH350015DK	Child	DSH	SANFORD BISMARCK	Sanford Watford City Podiatry Outreach - Sanford Watford City Podiatry Outreach	709 4th Ave NE Suite 1	Watford City	ND	Active
DSH350015DL	Child	DSH	SANFORD BISMARCK	Sanford Watford City Childrens Outreach - Sanford Watford City Childrens Outreach	709 4th Ave NE Suite 1	Watford City	ND	Active
DSH350015DM	Child	DSH	SANFORD BISMARCK	Sanford Watford City Dickson West OB Outreach - Sanford Watford City Dickson West OB Outreach	709 4th ave NE Suite 1	Watford City	ND	Active
DSH350015DN	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Oncology - Sanford West Dickinson Oncology	2615 Fairway Street	Dickinson	ND	Active
DSH350015DP	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Podiatry - Sanford West Dickinson Podiatry	2615 Fairway Street	Dickinson	ND	Active
DSH350015DQ	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Internal Medicine - Sanford West Dickinson Internal Medicine	2615 Fairway Street	Dickinson	ND	Active
DSH350015DR	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Surgery Center - Sanford West Dickinson Surgery Center	2615 Fairway Street	Dickinson	ND	Active
DSH350015DS	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Surgery - Sanford West Dickinson Surgery	2615 Fairway Street	Dickinson	ND	Active
DSH350015DT	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Speech Therapy - Sanford West Dickinson Speech Therapy	2615 Fairway Street	Dickinson	ND	Active
DSH350015DU	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Physical Therapy - Sanford West Dickinson Physical Therapy	2615 Fairway street	Dickinson	ND	Active
DSH350015DV	Child	DSH	SANFORD BISMARCK	Sanford West Dickinson Occupational Therapy - Sanford West Dickinson Occupational Therapy	2615 Fairway Street	Dickinson	ND	Active
DSH350015DW	Child	DSH	SANFORD BISMARCK	Sanford Sleep Disorder Clinic - Sanford Sleep Disorder Clinic	1809 East Century Avenue	Bismarck	ND	Active
DSH350015DX	Child	DSH	SANFORD BISMARCK	Sanford Dickinson Maternal Fetal Medicine - Sanford Dickinson Maternal Fetal Medicine	2615 Fairway Street	Dickinson	ND	Active
DSH350015DY	Child	DSH	SANFORD BISMARCK	Sanford Dickinson Behavioral Health - Sanford Dickinson Behavioral Health	33 9th street west	Dickinson	ND	Active
DSH350015DZ	Child	DSH	SANFORD BISMARCK	Sanford Bismarck Cardiology Outreach - Sanford Bismarck Cardiology Outreach	709 4th Ave NE suite 1	Watford City	ND	Active
DSH350015E	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Infectious Disease	222 N 7TH ST	BISMARCK	ND	Active
DSH350015EA	Child	DSH	SANFORD BISMARCK	Sanford Watford City Family Medicine - Sanford Watford City Family Medicine	709 4th Ave NE Suite 1	Watford City	ND	Active
DSH350015EB	Child	DSH	SANFORD BISMARCK	Sanford Interventional Radiology - Sanford Interventional Radiology	222 North 7th street	Bismarck	ND	Active
DSH350015EC	Child	DSH	SANFORD BISMARCK	Dickinson Cardiology Outreach - Dickinson Cardiology Outreach	2615 Fairway Street	Dickinson	ND	Active
DSH350015ED	Child	DSH	SANFORD BISMARCK	Dickinson Cardiac Device Outreach - Dickinson Cardiac Device Outreach	2615 Fairway Street	Dickinson	ND	Active
DSH350015EE	Child	DSH	SANFORD BISMARCK	Dickinson ENT Clinic Outreach - Dickinson ENT Clinic Outreach	2615 Fairway Street	Dickinson	ND	Active
DSH350015EF	Child	DSH	SANFORD BISMARCK	Dickinson Orthopedic Clinic Outreach - Dickinson Orthopedic Clinic Outreach	2615 Fairway Street	Dickinson	ND	Active
DSH350015EG	Child	DSH	SANFORD BISMARCK	Dickinson Maternal Fetal Ultrasound Clinic - Dickinson Maternal Fetal Ultrasound Clinic	2615 Fairway Street	Dickinson	ND	Active
DSH350015EH	Child	DSH	SANFORD BISMARCK	Dickinson East Diabetes Clinic - Dickinson East Diabetes Clinic	33 9th street west	Dickinson	ND	Active
DSH350015EJ	Child	DSH	SANFORD BISMARCK	Minot Nephrology Outreach Clinic - Minot Nephrology Outreach Clinic	801 21st Ave Se	Minot	ND	Active
DSH350015F	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Sanford Bismarck Pediatrics North	765 W INTERSTATE AVE	BISMARCK	ND	Active
DSH350015G	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Rehab Clinic	4535 Northern Sky Drive	BISMARCK	ND	Active
DSH350015H	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Cardiology Clinic	222 N 7TH ST	BISMARCK	ND	Active
DSH350015J	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Diabetes Care Clinic	515 E BROADWAY AVE	BISMARCK	ND	Active
DSH350015K	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Wound Care Clinic	515 E BROADWAY AVE	BISMARCK	ND	Active
DSH350015L	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Sanford State Street Radiology Clinic	3318 N 14TH ST	BISMARCK	ND	Active
DSH350015M	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Sanford State Street Clinic	3318 N 14TH ST	BISMARCK	ND	Active
DSH350015N	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Mandan North Radiology Clinic	910 18TH ST NW	MANDAN	ND	Active
DSH350015P	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Mandan North Family Medicine Clinic	910 18TH ST NW	MANDAN	ND	Active
DSH350015Q	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / East Interstate Ave Radiology Clinic	1800 E Interstate Ave	BISMARCK	ND	Active
DSH350015R	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / East Interstate Ave Family Medicine Clinic	1800 E Interstate Ave	BISMARCK	ND	Active
DSH350015S	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Mandan East Radiology Clinic	102 MANDAN AVE	MANDAN	ND	Active
DSH350015T	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Mandan East Family Medicine Clinic	102 MANDAN AVE	MANDAN	ND	Active
DSH350015U	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / South Radiology Clinic	1040 TACOMA AVE	BISMARCK	ND	Active
DSH350015V	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / South Family Medicine Clinic	1040 TACOMA AVE	BISMARCK	ND	Active
DSH350015W	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Pain Management	414 N 7TH ST	BISMARCK	ND	Active
DSH350015X	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Behavioral Health	1800 E Interstate Ave	BISMARCK	ND	Active
DSH350015Y	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Hearing Center	701 E ROSSER AVE	BISMARCK	ND	Active
DSH350015Z	Child	DSH	SANFORD BISMARCK	SANFORD BISMARCK / Ear, Nose & Throat Clinic	701 E ROSSER AVE	BISMARCK	ND	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Thompson, Leigh Ann Chief Financial Officer Sanford Bismarck 7013236720	8/25/2024 12:56 PM
Details	340B ID	Update	New Registration		DSH350015DL	8/25/2024 12:56 PM
Details	Entity Subname	Update	New Registration	Sanford Watford City Childrens Outreach	Sanford Watford City Childrens Outreach - Sanford Watford City Childrens Outreach	8/25/2024 12:56 PM
Dates	Participating Approval Date	Update	New Registration		8/25/2024 12:56:04 PM	8/25/2024 12:56 PM
Details	State	Update	New Registration	Pending	Approved	8/25/2024 12:56 PM
Dates	Signed By Date	Update	New Registration		7/11/2024 5:03:10 PM	8/25/2024 12:56 PM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/25/2024 12:56 PM
Addresses	Main Address	Insert	New Registration		709 4th Ave NE Suite 1 Watford City, ND 58854	7/11/2024 5:00 PM
Addresses	Billing Address	Insert	New Registration		Sanford Bismarck 300 North 7th St Bismarck, ND 58501	7/11/2024 5:00 PM
Addresses	Shipping Address	Insert	New Registration		Sanford Bismarck 300 North 7th St Bismarck, ND 58501	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1456048	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1458812	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1458769	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1461466	7/11/2024 5:00 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1477631745	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538245634	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1598185597	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1669555744	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720075377	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1811941172	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1669524351	7/11/2024 5:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		ND	7/11/2024 5:00 PM
Contacts	Primary Contact	Insert	New Registration		Savageau, John Director - Pharmacy Sanford Bismarck 7013236186	7/11/2024 5:00 PM
Contacts	Authorizing Official	Insert	New Registration		Thompson, Leigh Ann Chief Financial Officer Sanford Bismarck 7013236720	7/11/2024 5:00 PM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 5:00 PM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 5:00 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 5:00 PM
Details	Grant Number	Insert	New Registration			7/11/2024 5:00 PM
Details	340B ID	Insert	New Registration			7/11/2024 5:00 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 5:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 5:00 PM
Details	Medicare Provider Number	Insert	New Registration		350015	7/11/2024 5:00 PM
Details	Entity Name	Insert	New Registration		SANFORD BISMARCK	7/11/2024 5:00 PM
Details	NOFO Number	Insert	New Registration			7/11/2024 5:00 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2024 5:00 PM
Details	Entity Subname	Insert	New Registration		Sanford Watford City Childrens Outreach	7/11/2024 5:00 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 5:00 PM
Details	State	Insert	New Registration		Pending	7/11/2024 5:00 PM
Dates	Registration Date	Insert	New Registration		7/11/2024 5:00:15 PM	7/11/2024 5:00 PM
Dates	Signed By Date	Insert	New Registration			7/11/2024 5:00 PM
Dates	Start Date	Insert	New Registration			7/11/2024 5:00 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 5:00 PM
Terminations	Termination Date	Insert	New Registration			7/11/2024 5:00 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 5:00 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 5:00 PM