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COUNTRY DRUG STORE
DSH350015 SANFORD BISMARCK
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Covered Entity Details
Entity Name
SANFORD BISMARCK
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH350015
Entity Address
300 N 7TH ST
BISMARCK, ND 58501
Medicare Provider Number
350015
Participating Start Date
7/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
COUNTRY DRUG STORE
Pharmacy Address
116 NORTH AVE E
RICHARDTON, ND 58652-7044
Pharmacy Comments
Contract Details
Approval Date
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kirk Cristy, Vice President Finance
(701) 323-6000 Ext: 6310
Contract Pharmacy Representative
COUNTRY DRUG STORE
DOREEN STUDSRUD, PRESIDENT
(701) 974-3558
Signed By Date
7/17/2023
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