Covered Entity Details

RRC350011-37 Sanford Medical Center Fargo (Terminated) - information as of 5/6/2025 11:11:36 PM

Main Details

Name

Sanford Medical Center Fargo

Subdivision Name

Sanford Physical Medicine Fargo PBB

Type

Rural Referral Center

Rural

340B ID

RRC350011-37

Medicare Provider Number

350011

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/2/2013

Participating Start Date

4/1/2013

Participating Approval Date

3/12/2013

Last Recertification Date

8/10/2016

Termination Date
Termination Reason

4/1/2017
Change of covered entity type

Contacts

Authorizing Official

Sanford Medical Center Fargo
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314

Primary Contact

Sanford Health
Jesse Breidenbach, Vice President, Pharmacy
(701) 234-6887

Addresses

Street Address

736 Broadway North
Fargo, ND 58102

Billing Address

Sanford Medical Center Fargo
801 Broadway North
Fargo, ND 58102

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?
No

Shipping Addresses

Shipping Address 1

Sanford Medical Center Fargo
801 Broadway North
Fargo, ND 58102

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
RRC350011-01	Child	RRC	Sanford Medical Center Fargo	Sanford Dialysis Thief River Falls	120 Labree Avenue South	Thief River Falls	MN	Terminated
RRC350011-02	Child	RRC	Sanford Medical Center Fargo	Sanford Dialysis Morris	400 First Street East	Morris	MN	Terminated
RRC350011-03	Child	RRC	Sanford Medical Center Fargo	Sanford Dialysis Detroit Lakes	114 East Frazee Street	Detroit Lakes	MN	Terminated
RRC350011-04	Child	RRC	Sanford Medical Center Fargo	Sanford Dialysis Bemidji	1300 Anne Street Northwest	Bemidji	MN	Terminated
RRC350011-05	Child	RRC	Sanford Medical Center Fargo	Sanford Dialysis Fargo	2801 South University Drive	Fargo	ND	Terminated
RRC350011-06	Child	RRC	Sanford Medical Center Fargo	Sanford Dialysis Red Lake	24760 Hospital Drive	Red Lake	MN	Terminated
RRC350011-07	Child	RRC	Sanford Medical Center Fargo	Sanford Medical Center - Roger Maris Cancer Center	820 4th Street North	Fargo	ND	Terminated
RRC350011-08	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Diabetes Educators Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-09	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Nutrition Therapy Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-10	Child	RRC	Sanford Medical Center Fargo	Sanford Eating Disorders Fargo PBB	1717 South University Drive	Fargo	ND	Terminated
RRC350011-100	Child	RRC	Sanford Medical Center Fargo	Sanford Medical Center Fargo / Home Dialysis Bemidji	1300 Anne Street Northwest	Bemidji	MN	Terminated
RRC350011-101	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center Fargo / Home Dialysis Fargo	2801 South University Drive	Fargo	ND	Terminated
RRC350011-102	Child	RRC	Sanford Medical Center Fargo	Sanford Medical Center - Fargo / Ortho Surgery Center PACU	2301 25th Street South	Fargo	ND	Terminated
RRC350011-103	Child	RRC	Sanford Medical Center Fargo	Sanford Medical Center - Fargo / Orthopedic Surgery Center	2301 25th Street South	Fargo	ND	Terminated
RRC350011-104	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center - Fargo / Sanford Southpointe Internal Medicine	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-105	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center Fargo / Sanford Southpointe Family Medicine	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-11	Child	RRC	Sanford Medical Center Fargo	Sanford SU Eye Services MDs Fargo PBB	1717 South University Drive	Fargo	ND	Terminated
RRC350011-12	Child	RRC	Sanford Medical Center Fargo	Sanford Oral Surgery Fargo PBB	1717 South University Drive	Fargo	ND	Terminated
RRC350011-13	Child	RRC	Sanford Medical Center Fargo	Sanford Bariatric Surgery Fargo PBB	1717 South University Drive	Fargo	ND	Terminated
RRC350011-14	Child	RRC	Sanford Medical Center Fargo	Sanford West Fargo Family Medicine Fargo PBB	1220 Sheyenne St	West Fargo	ND	Terminated
RRC350011-15	Child	RRC	Sanford Medical Center Fargo	Sanford West Fargo OB/GYN Fargo PBB	1220 Sheyenne St	West Fargo	ND	Terminated
RRC350011-16	Child	RRC	Sanford Medical Center Fargo	Sanford Southwest Pediatrics Fargo PBB	2701 13th Ave S	Fargo	ND	Terminated
RRC350011-17	Child	RRC	Sanford Medical Center Fargo	Sanford SU Walk In Clinic Fargo PBB	1720 South University Drive	Fargo	ND	Terminated
RRC350011-18	Child	RRC	Sanford Medical Center Fargo	Sanford SU Pain Clinic Fargo PBB	1720 South University Drive	Fargo	ND	Terminated
RRC350011-19	Child	RRC	Sanford Medical Center Fargo	Sanford Child/Adolescent Maltreatment Fargo PBB	100 4th St S	Fargo	ND	Terminated
RRC350011-20	Child	RRC	Sanford Medical Center Fargo	Sanford Child Psych Fargo PBB	100 4th St S	Fargo	ND	Terminated
RRC350011-21	Child	RRC	Sanford Medical Center Fargo	Sanford Adult Psychology Fargo PBB	1301 8th Street South	Moorhead	MN	Terminated
RRC350011-22	Child	RRC	Sanford Medical Center Fargo	Sanford Adult Psychiatry Fargo PBB	1301 8th Street South	Moorhead	MN	Terminated
RRC350011-23	Child	RRC	Sanford Medical Center Fargo	Sanford Neurology Fargo PBB	700 1st Ave S	Fargo	ND	Terminated
RRC350011-24	Child	RRC	Sanford Medical Center Fargo	Sanford Neuropsychology Fargo PBB	100 4th St S	Fargo	ND	Terminated
RRC350011-25	Child	RRC	Sanford Medical Center Fargo	Sanford Neurosurgery Fargo PBB	700 1st Ave S	Fargo	ND	Terminated
RRC350011-26	Child	RRC	Sanford Medical Center Fargo	Sanford SU Sleep Lab Fargo PBB	2801 South University Drive	Fargo	ND	Terminated
RRC350011-27	Child	RRC	Sanford Medical Center Fargo	Sanford North Fargo Family Medicine Fargo PBB	2601 Broadway North	Fargo	ND	Terminated
RRC350011-28	Child	RRC	Sanford Medical Center Fargo	Sanford Osgood Dermatology Fargo PBB	4656 40th Ave S	Fargo	ND	Terminated
RRC350011-29	Child	RRC	Sanford Medical Center Fargo	Sanford Reproductive Medicine Fargo PBB	1111 Harwood Dr S Fargo	Fargo	ND	Terminated
RRC350011-30	Child	RRC	Sanford Medical Center Fargo	Sanford Plastic Surgery Fargo PBB	2801 South University Drive	Fargo	ND	Terminated
RRC350011-31	Child	RRC	Sanford Medical Center Fargo	Sanford Nephrology Fargo PBB	736 Broadway North	Fargo	ND	Terminated
RRC350011-32	Child	RRC	Sanford Medical Center Fargo	Sanford Medical Oncology Fargo PBB	820 4th Street North	Fargo	ND	Terminated
RRC350011-33	Child	RRC	Sanford Medical Center Fargo	Sanford Infectious Disease Fargo PBB	736 Broadway North	Fargo	ND	Terminated
RRC350011-34	Child	RRC	Sanford Medical Center Fargo	Sanford Psych Oncology Fargo PBB	820 4th Street North	Fargo	ND	Terminated
RRC350011-35	Child	RRC	Sanford Medical Center Fargo	Sanford Pediatric Oncology PBB	820 4th Street North	Fargo	ND	Terminated
RRC350011-36	Child	RRC	Sanford Medical Center Fargo	Sanford Chiropractic Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-37	Child	RRC	Sanford Medical Center Fargo	Sanford Physical Medicine Fargo PBB	736 Broadway North	Fargo	ND	Terminated
RRC350011-38	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Eye Services Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-39	Child	RRC	Sanford Medical Center Fargo	Sanford Transplant Surgery Fargo PBB	736 Broadway North	Fargo	ND	Terminated
RRC350011-40	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Endocrinology Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-41	Child	RRC	Sanford Medical Center Fargo	Sanford Hand Surgery Fargo PBB	2301 25th Street South	Fargo	ND	Terminated
RRC350011-42	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Rheumatology Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-43	Child	RRC	Sanford Medical Center Fargo	Sanford Orthopedic Clinic Fargo PBB	2301 25th Street South	Fargo	ND	Terminated
RRC350011-44	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Allergy Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-45	Child	RRC	Sanford Medical Center Fargo	Sanford Hawley General PBB	1412 Main St	Hawley	MN	Terminated
RRC350011-46	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe Podiatry Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-47	Child	RRC	Sanford Medical Center Fargo	Sanford Southpointe OB/GYN Fargo PBB	2400 32nd Avenue South	Fargo	ND	Terminated
RRC350011-48	Child	RRC	Sanford Medical Center Fargo	Sanford Moorhead Family Medicine Fargo PBB	4000 28th Ave S	Moorhead	MN	Terminated
RRC350011-49	Child	RRC	Sanford Medical Center Fargo	Sanford Moorhead Internal Medicine Fargo PBB	4000 28th Ave S	Moorhead	MN	Terminated
RRC350011-50	Child	RRC	Sanford Medical Center Fargo	Sanford Same Day Surgery Center	321 8th Avenue North	Fargo	ND	Terminated
RRC350011-51	Child	RRC	Sanford Medical Center Fargo	Sanford Radiation Oncology Fargo PBB	820 4th Street North	Fargo	ND	Terminated
RRC350011-52	Child	RRC	Sanford Medical Center Fargo	Sanford SU Eating Disorder Unit Partial Hospital Program	1720 South University Drive	Fargo	ND	Terminated
RRC350011-53	Child	RRC	Sanford Medical Center Fargo	Sanford SU Partial Psych	1720 South University Drive	Fargo	ND	Terminated
RRC350011-54	Child	RRC	Sanford Medical Center Fargo	Sanford SU Speech Therapy	1720 South University Drive	Fargo	ND	Terminated
RRC350011-55	Child	RRC	Sanford Medical Center Fargo	Sanford SU Occupational Therapy	1720 South University Drive	Fargo	ND	Terminated
RRC350011-56	Child	RRC	Sanford Medical Center Fargo	Sanford SU Recreational Therapy	1720 South University Drive	Fargo	ND	Terminated
RRC350011-57	Child	RRC	Sanford Medical Center Fargo	Sanford SU Physical Therapy	1720 South University Drive	Fargo	ND	Terminated
RRC350011-58	Child	RRC	Sanford Medical Center Fargo	Sanford SU EKG	1720 South University Drive	Fargo	ND	Terminated
RRC350011-59	Child	RRC	Sanford Medical Center Fargo	Sanford SU Respiratory Therapy	1720 South University Drive	Fargo	ND	Terminated
RRC350011-60	Child	RRC	Sanford Medical Center Fargo	Sanford SU MRI	1720 South University Drive	Fargo	ND	Terminated
RRC350011-61	Child	RRC	Sanford Medical Center Fargo	Sanford SU CT Scan	1720 South University Drive	Fargo	ND	Terminated
RRC350011-62	Child	RRC	Sanford Medical Center Fargo	Sanford SU General Radiology	1720 South University Drive	Fargo	ND	Terminated
RRC350011-63	Child	RRC	Sanford Medical Center Fargo	Sanford SU Anesthesia	1720 South University Drive	Fargo	ND	Terminated
RRC350011-64	Child	RRC	Sanford Medical Center Fargo	Sanford SU Operating Room	1720 South University Drive	Fargo	ND	Terminated
RRC350011-65	Child	RRC	Sanford Medical Center Fargo	Sanford PACU	1720 South University Drive	Fargo	ND	Terminated
RRC350011-66	Child	RRC	Sanford Medical Center Fargo	Sanford SU Sleep Lab	2801 South University Drive	Fargo	ND	Terminated
RRC350011-67	Child	RRC	Sanford Medical Center Fargo	Sanford SU Eye PACU	1717 South University Drive	Fargo	ND	Terminated
RRC350011-68	Child	RRC	Sanford Medical Center Fargo	Sanford SU Eye Anesthesiology	1717 South University Drive	Fargo	ND	Terminated
RRC350011-69	Child	RRC	Sanford Medical Center Fargo	Sanford SU Eye Operating Room	1717 South University Drive	Fargo	ND	Terminated
RRC350011-70	Child	RRC	Sanford Medical Center Fargo	Sanford Moorhead Clinic / Pediatrics	4000 28th Ave S	Moorhead	MN	Terminated
RRC350011-71	Child	RRC	Sanford Medical Center Fargo	Sanford Moorhead Clinic / OB/GYN	4000 28th Ave S	Moorhead	MN	Terminated
RRC350011-72	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford IM Wellness Center	2960 Seter Parkway	Fargo	ND	Terminated
RRC350011-73	Child	RRC	SANFORD MEDICAL CENTER FARGO	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Multiple Sclerosis	736 Broadway North	Fargo	ND	Terminated
RRC350011-74	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Cancer Survivorship Clinic	736 Broadway North	Fargo	ND	Terminated
RRC350011-75	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING-Sanford CTC - Huntingtons Disease / Sanford CTC - Huntingtons Disease	736 Broadway North	Fargo	ND	Terminated
RRC350011-76	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Parkinsons Disease	736 Broadway North	Fargo	ND	Terminated
RRC350011-77	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Children's Weight Mgmt	736 Broadway North	Fargo	ND	Terminated
RRC350011-78	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Diabetes Peds	736 Broadway North	Fargo	ND	Terminated
RRC350011-79	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Brain Injury Adult	736 Broadway North	Fargo	ND	Terminated
RRC350011-80	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - CH Brain Injury	736 Broadway North	Fargo	ND	Terminated
RRC350011-81	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Cerebral Palsy	736 Broadway North	Fargo	ND	Terminated
RRC350011-82	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Downs Syndrome	736 Broadway North	Fargo	ND	Terminated
RRC350011-83	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Metabolic Service	736 Broadway North	Fargo	ND	Terminated
RRC350011-84	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Growth/Development	736 Broadway North	Fargo	ND	Terminated
RRC350011-85	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Cystic Fibrosis	736 Broadway North	Fargo	ND	Terminated
RRC350011-86	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford Coordinated Treatment Center - Muscular Dystrophy Association	736 Broadway North	Fargo	ND	Terminated
RRC350011-87	Child	RRC	Sanford Medical Center Fargo	Sanford Coordinated Treatment Center - Palliative Care	736 Broadway North	Fargo	ND	Terminated
RRC350011-88	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford Infusions SU 4A	1720 South University Drive	Fargo	ND	Terminated
RRC350011-89	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford SU 4A Ortho Surg	1720 South University Drive	Fargo	ND	Terminated
RRC350011-90	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford South University Feeding Disorders Prtl Hosp Prog	1720 South University Drive	Fargo	ND	Terminated
RRC350011-91	Child	RRC	Sanford Medical Center Fargo	Sanford South University Partial Psych Child	1711 South University Drive	Fargo	ND	Terminated
RRC350011-92	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Craniofacial	736 Broadway North	Fargo	ND	Terminated
RRC350011-93	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Feeding/Swallowing	736 Broadway North	Fargo	ND	Terminated
RRC350011-94	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Peds Development	736 Broadway North	Fargo	ND	Terminated
RRC350011-95	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Myelodysplasia	736 Broadway North	Fargo	ND	Terminated
RRC350011-96	Child	RRC	Sanford Medical Center Fargo	SANFORD BROADWAY MEDICAL BUILDING / Sanford CTC - Spinal Cord	736 Broadway North	Fargo	ND	Terminated
RRC350011-97	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center Fargo / Sanford Infusion Center PBB	820 4th Street North	Fargo	ND	Terminated
RRC350011-98	Child	RRC	SANFORD MEDICAL CENTER - FARGO	Sanford Medical Center Fargo / Sanford Same Day Surgery Post Anesthesia Care Unit	321 8th Avenue North	Fargo	ND	Terminated
RRC350011-99	Child	RRC	Sanford Medical Center Fargo	Sanford Medical Center Fargo / Home Dialysis Detroit Lakes	114 East Frazee Street	Detroit Lakes	MN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7014172326	Lawrence, Tiffany President and CEO, Fargo Sanford Medical Center Fargo 7014172314	10/20/2023 12:34 PM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	Breidenbach, Jesse Vice President, Pharmacy Sanford Health 7012346887	1/9/2023 6:20 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse L System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887-6887	Breidenbach, Jesse System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	11/19/2021 11:21 AM
Contacts	Primary Contact	Update	Change Request	Breidenbach, Jesse L System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	Breidenbach, Jesse L System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887-6887	9/15/2021 4:53 PM
Contacts	Primary Contact	Update	Change Request	Breidenbach, Jesse System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	Breidenbach, Jesse L System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	9/15/2021 4:51 PM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Senior Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	Breidenbach, Jesse System Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	4/6/2021 2:37 PM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Senior Executive Director, Pharmacy Sanford Medical Center Fargo 7012346887	1/8/2020 3:10 PM
Contacts	Authorizing Official	Update	Profile Change Request	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7012346449	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7014172326	8/21/2018 3:17 PM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:36 AM
Contacts	Primary Contact	Update	Recertification	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:22 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Senior Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:20 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:18 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:17 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:17 AM
Contacts	Primary Contact	Update	Contract Pharmacy Change Request	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 10:17 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	Breidenbach, Jesse Enterprise Director, Enterprise Pharmacy Sanford Medical Center Fargo 7014172307	8/21/2018 9:55 AM
Contacts	Authorizing Official	Update		Lawrence, Tiffany Vice President Finance 7012346449	Lawrence, Tiffany Vice President Finance Sanford Medical Center Fargo 7012346449	9/26/2017 9:20 AM
Contacts	Primary Contact	Update	Profile Change Request	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7012345616	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7014172307	9/20/2017 4:38 PM
Contacts	Primary Contact	Update		Breidenbach, Jesse Director of Pharmacy 7012345616	Breidenbach, Jesse Director of Pharmacy Sanford Medical Center Fargo 7012345616	9/19/2017 12:15 PM
Contacts	Primary Contact	Insert			Breidenbach, Jesse Director of Pharmacy 7012345616	8/1/2017 9:23 AM
Contacts	Authorizing Official	Insert			Lawrence, Tiffany Vice President Finance 7012346449	8/1/2017 9:23 AM
Contacts	Signed By	Insert			Leclerc, Martha Vice President 7012346248	3/16/2017 5:33 PM
Details	State	Update		Active	Terminated	2/14/2017 6:26 PM
Terminations	Termination Comments	Update			Registration of Parent Entity as a new entity of DSH was approved.	2/14/2017 6:26 PM
Terminations	Termination Date	Update			4/1/2017 12:00:00 AM	2/14/2017 6:26 PM
Terminations	Termination Effective Date	Update			4/1/2017 12:00:00 AM	2/14/2017 6:26 PM
Terminations	Termination Reason	Update			Change of covered entity type	2/14/2017 6:26 PM
Addresses	Main Address	Insert			736 Broadway North Fargo, ND 58102	12/22/2016 12:05 PM
Addresses	Billing Address	Insert			Sanford Medical Center Fargo 801 Broadway North Fargo, ND 58102	12/22/2016 12:05 PM
Addresses	Shipping Address	Insert			Sanford Medical Center Fargo 801 Broadway North Fargo, ND 58102	12/22/2016 12:05 PM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 4:20 PM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/7/2015 12:00:00 AM	8/7/2015 10:03 AM
Details	Last Recertification Date	Update		8/27/2013 12:00:00 AM	8/19/2014 12:00:00 AM	8/19/2014 12:52 PM
Details	Last Recertification Date	Update			8/27/2013 12:00:00 AM	8/27/2013 7:42 AM
Details	340B ID	Update		ISJMRRC350011-37	RRC350011-37	3/12/2013 10:48 AM
Dates	Participating Approval Date	Update			3/12/2013 12:00:00 AM	3/12/2013 10:48 AM
Details	State	Update		Pending	Active	3/12/2013 10:48 AM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	3/12/2013 10:48 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISJMRRC350011-37	3/7/2013 4:36 PM
Details	Last Recertification Date	Insert				1/2/2013 10:54 AM
Details	Grant Number	Insert				1/2/2013 10:54 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/2/2013 10:54 AM
Details	Is Authorizing Official EHB Data	Insert				1/2/2013 10:54 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/2/2013 10:54 AM
Details	Medicare Provider Number	Insert			350011	1/2/2013 10:54 AM
Details	Entity Name	Insert			Sanford Medical Center Fargo	1/2/2013 10:54 AM
Details	Program Code	Insert			RRC	1/2/2013 10:54 AM
Details	Entity Subname	Insert			Sanford Physical Medicine Fargo PBB	1/2/2013 10:54 AM
Dates	Participating Approval Date	Insert				1/2/2013 10:54 AM
Details	State	Insert			Pending	1/2/2013 10:54 AM
Dates	Registration Date	Insert			1/2/2013 12:00:00 AM	1/2/2013 10:54 AM
Dates	Signed By Date	Insert			1/2/2013 12:00:00 AM	1/2/2013 10:54 AM
Dates	Start Date	Insert				1/2/2013 10:54 AM
Terminations	Termination Comments	Insert				1/2/2013 10:54 AM
Terminations	Termination Date	Insert				1/2/2013 10:54 AM
Terminations	Termination Effective Date	Insert				1/2/2013 10:54 AM
Terminations	Termination Reason	Insert				1/2/2013 10:54 AM