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CORAM ALTERNATE SITE SERVICES, INC.
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
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
2901 FRONTAGE ROAD SOUTH, 10 HIGHWAY EAS
SUITE 7
MOORHEAD, MN 56560
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/14/2021
Business decision by covered entity and/or pharmacy
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
7/15/2020
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