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GRAND ST. PAUL CVS, L.L.C.
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
GRAND ST. PAUL CVS, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 5616
329 FRAZEE STREET EAST
DETROIT LAKES, MN 56501
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
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