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SANFORD PHARMACY ROGER MARIS
RRC350011-00 Sanford Medical Center Fargo
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Covered Entity Details
Entity Name
Sanford Medical Center Fargo
Subdivision Name
Type
Rural Referral Center
340B ID
RRC350011-00
Entity Address
801 Broadway North
Fargo, ND 58102-3641
Medicare Provider Number
350011
Participating Start Date
7/1/2012
Last Recertification Date
8/10/2016
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
SANFORD PHARMACY ROGER MARIS
Pharmacy Address
820 4TH STREET NORTH
FARGO, ND 58122
Pharmacy Comments
Contract Details
Approval Date
3/21/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Martha Leclerc, Vice President
(701) 234-6248
Contract Pharmacy Representative
Robert Biberdorf, Director of Pharmacy
(701) 234-5603
Signed By Date
1/8/2013
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