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PERHAM HEALTH 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
PERHAM HEALTH PHARMACY
Pharmacy Address
1000 CONEY ST W
PERHAM, MN 56573-2102
Pharmacy Comments
03/16/2012 changed name and address (was East Ottertail Pharmacy 665 3rd st sw)
Contract Details
Approval Date
10/18/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
Perham Health
Tracey Bovkoon, Director of Pharmacy
(218) 347-1571
Signed By Date
10/18/2022
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