Contract Pharmacy Details

PRESCRIPTION SHOP
RRC350011-00 Sanford Medical Center Fargo

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

PRESCRIPTION SHOP

Pharmacy Address

1210 SHEYENNE ST
WEST FARGO, ND 58078

Pharmacy Comments

Contract Details

Approval Date

4/21/2014

Contract Begin Date

7/1/2014

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

Jon Holland, Owner
(701) 282-4665

Signed By Date

4/21/2014