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GREENBUSH PHARMACY
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
GREENBUSH PHARMACY
Pharmacy Address
152 MAIN ST N
P O BOX 39
GREENBUSH, MN 56726-4015
Pharmacy Comments
Contract Details
Approval Date
4/18/2022
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
Mattson Pharmacy Incorporated
Dean Mattson, Pharmacy Owner
(218) 343-1856
Signed By Date
4/18/2022
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