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RRC350011-07 Sanford Medical Center Fargo (Terminated)
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Main Details
Name
Sanford Medical Center Fargo
Subdivision Name
Sanford Medical Center - Roger Maris Cancer Center
Type
Rural Referral Center
Rural
No
340B ID
RRC350011-07
Medicare Provider Number
350011
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/20/2012
Participating Start Date
10/1/2012
Participating Approval Date
8/17/2012
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
820 4th Street North
Fargo, ND 58102
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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7/26/12 - Documents requested CA
07/26/2012
May 2025
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