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NORTHPORT DRUG
DSH350011 SANFORD MEDICAL CENTER FARGO
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Covered Entity Details
Entity Name
SANFORD MEDICAL CENTER FARGO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH350011
Entity Address
801 BROADWAY NORTH
FARGO, ND 58102
Medicare Provider Number
350011
Participating Start Date
4/1/2017
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
NORTHPORT DRUG
Pharmacy Address
2522 BROADWAY N
NORTHPORT SHOPPING CENTER
FARGO, ND 58102-1405
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
Johnson Drug Co, dba Northport Drug
Rachel Kupfer, Owner/Pharmacist
(701) 235-5543
Signed By Date
7/17/2018
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