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RRC350011-00 Sanford Medical Center Fargo (Terminated)
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Main Details
Name
Sanford Medical Center Fargo
Subdivision Name
Type
Rural Referral Center
Rural
No
340B ID
RRC350011-00
Medicare Provider Number
350011
Additional Details
Current Program Status
Terminated
Registration Date
5/25/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/18/2012
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
801 Broadway North
Fargo, ND 58102-3641
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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