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SANFORD PHARMACY ROGER MARIS
DSH430027 Sanford USD Medical Center
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Covered Entity Details
Entity Name
Sanford USD Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430027
Entity Address
1305 W 18th Street
Sioux Falls, SD 57117-5039
Medicare Provider Number
430027
Participating Start Date
1/1/2013
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
SANFORD PHARMACY ROGER MARIS
Pharmacy Address
820 4TH STREET NORTH
FARGO, ND 58122
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/28/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cole A Turner, Vice President, Finance
(605) 328-6940
Contract Pharmacy Representative
Sanford Medical Center Fargo
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Signed By Date
7/15/2019
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