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THE MEDICINE SHOPPE
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
THE MEDICINE SHOPPE
Pharmacy Address
116 2ND AVE NW
MANDAN, ND 58554
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Ownership change
Contacts
Covered Entity Signing Official
Kirk Cristy, Vice President Finance
(701) 323-6000 Ext: 6310
Contract Pharmacy Representative
The Medicine Shoppe Mandan
Bob Gustafson, Owner
(701) 663-1151
Signed By Date
7/12/2019
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