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THRIFTY WHITE PHARMACY #103
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
THRIFTY WHITE PHARMACY #103
Pharmacy Address
503 3RD AVE E # 100
ALEXANDRIA, MN 56308-1503
Pharmacy Comments
Contract Details
Approval Date
4/5/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
4/5/2022
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