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SANFORD PHARMACY BROADWAY
HM10193 SANFORD MEDICAL CENTER FARGO
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Covered Entity Details
Entity Name
SANFORD MEDICAL CENTER FARGO
Subdivision Name
SANFORD HEALTH CENTER FOR BLEEDING AND CLOTTING DISORDERS
Type
Comprehensive Hemophilia Treatment Center
340B ID
HM10193
Entity Address
801 Broadway N
FARGO, ND 58102
Grant Number
H30MC24052
Participating Start Date
1/1/1997
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
SANFORD PHARMACY BROADWAY
Pharmacy Address
737 BROADWAY N
Fargo, ND 58102
Pharmacy Comments
Contract Details
Approval Date
10/10/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/19/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
Sanford Health
Jesse Breidenbach, Vice President, Pharmacy
(701) 234-6887
Signed By Date
10/10/2016
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