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SANFORD PHARMACY BROADWAY
DSH350015 SANFORD BISMARCK
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Covered Entity Details
Entity Name
SANFORD BISMARCK
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH350015
Entity Address
300 N 7TH ST
BISMARCK, ND 58501
Medicare Provider Number
350015
Participating Start Date
7/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SANFORD PHARMACY BROADWAY
Pharmacy Address
737 BROADWAY N
Fargo, ND 58102
Pharmacy Comments
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/4/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kirk Cristy, Vice President Finance
(701) 323-6000 Ext: 6310
Contract Pharmacy Representative
Sanford Health
Jesse Breidenbach, Vice President, Pharmacy
(701) 234-6887
Signed By Date
10/11/2018
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