Contract Pharmacy Details

AMERICAN DRUG STORES DELAWARE, L.L.C.
DSH350011 SANFORD MEDICAL CENTER FARGO

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

AMERICAN DRUG STORES DELAWARE, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08613
1321 19TH AVE NORTH
FARGO, ND 58102

Pharmacy Comments

Contract Details

Approval Date

1/11/2019

Contract Begin Date

4/1/2019

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/11/2019

340B Drug Pricing Program Database