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MEDICAL PHARMACY MOORHEAD AZOOL
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
MEDICAL PHARMACY MOORHEAD AZOOL
Pharmacy Address
950 40TH AVE S STE 103
MOORHEAD, MN 56560
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tiffany Lawrence, President and CEO, Fargo
(701) 417-2314
Contract Pharmacy Representative
MPND Inc
Sheila Nudell, Pharmacy manager
(218) 233-7365
Signed By Date
7/11/2017
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