Provider Demographics
NPI:1235173519
Name:SANFORD CLINIC NORTH
Entity Type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:SANFORD PHARMACY BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-328-8380
Mailing Address - Street 1:737 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4421
Mailing Address - Country:US
Mailing Address - Phone:701-234-2416
Mailing Address - Fax:701-234-2433
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4421
Practice Address - Country:US
Practice Address - Phone:701-234-2416
Practice Address - Fax:701-234-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND309332B00000X, 3336C0003X, 3336H0001X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1235173519Medicaid
35-00712OtherNCPDP
SD1235173519Medicaid
ND21587Medicaid
MN1235173519Medicaid