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SANFORD PHARMACY ROGER MARIS
DSH350011 SANFORD MEDICAL CENTER FARGO
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Covered Entity Details
Entity Name
SANFORD MEDICAL CENTER FARGO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH350011
Entity Address
801 BROADWAY NORTH
FARGO, ND 58102
Medicare Provider Number
350011
Participating Start Date
4/1/2017
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SANFORD PHARMACY ROGER MARIS
Pharmacy Address
820 4TH STREET NORTH
FARGO, ND 58122
Pharmacy Comments
Contract Details
Approval Date
2/23/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2020
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
2/23/2017
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