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SANFORD PHARMACY ROGER MARIS
DSH240100 Sanford Bemidji Medical Center
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Covered Entity Details
Entity Name
Sanford Bemidji Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240100
Entity Address
1300 ANNE STREET NW
BEMIDJI, MN 56601
Medicare Provider Number
240100
Participating Start Date
10/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
SANFORD PHARMACY ROGER MARIS
Pharmacy Address
820 4TH STREET NORTH
FARGO, ND 58122
Pharmacy Comments
Contract Details
Approval Date
4/14/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa Sue Miller, Chief Financial Officer
(218) 333-5523
Contract Pharmacy Representative
Sanford Health
Jesse Breidenbach, Vice President, Pharmacy
(701) 234-6887
Signed By Date
4/14/2024
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