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THRIFTY WHITE PHARMACY #068
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
THRIFTY WHITE PHARMACY #068
Pharmacy Address
4255 30TH AVE S
FARGO, ND 58104
Pharmacy Comments
Contract Details
Approval Date
1/14/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
Thrifty White
Zach Winter, Corporate Manager
(763) 248-7554
Signed By Date
1/14/2016
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