Provider Demographics
NPI:1568789121
Name:SANFORD MEDICAL CENTER FARGO
Entity Type:Organization
Organization Name:SANFORD MEDICAL CENTER FARGO
Other - Org Name:SANFORD PHARMACY DETROIT LAKES
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 1:1245 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3905
Mailing Address - Country:US
Mailing Address - Phone:701-234-2121
Mailing Address - Fax:
Practice Address - Street 1:1245 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3905
Practice Address - Country:US
Practice Address - Phone:218-846-2276
Practice Address - Fax:701-234-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2635073336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124937OtherPK
MN1568789121Medicaid
MN1213550046Medicare NSC