Covered Entity Details

DSH100281A MEMORIAL HOSPITAL WEST (Active) - information as of 5/20/2025 11:35:10 PM

Main Details

Name

MEMORIAL HOSPITAL WEST

Subdivision Name

MCI WEST BCC INFUS 3

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100281A

Medicare Provider Number

100281

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

12/11/2007

Participating Start Date

1/1/2008

Participating Approval Date

12/12/2007

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Memorial Hospital West
JOSEPH STUCZYNSKI, CEO
(954) 844-6871

Primary Contact

Memorial Healthcare System
Alexsandra Soto, Director, 340B Program
(954) 276-1771

Addresses

Street Address

12235 Pines Blvd.
PEMBROKE PINES, FL 33026

Billing Address

Memorial Healthcare System
PO Box 269001
Attn: Accounts Payable
Pembroke Pines, FL 33026

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
4/7/2010- AMDP- NETWORK- SOUTH BROWARD HOSPITAL DISTRICT; 4/7/08-REVISED TO SHIP-TO ADDRESS (WAS 603 N. FLAMINGO RD.)	12/11/2007

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
FL	010252100	1134102080

Shipping Addresses

Shipping Address 1

South Broward Hospital District/ Memorial Cancer institute at Memorial Hospital West
12235 Pines Blvd
Suite 4201
Pembroke Pines, FL 33036

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Last Updated On
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL REGIONAL HOSPITAL PRIMARY CARE	4105 PEMBROKE RD.	HOLLYWOOD	FL	33021	02/26/2020	04/01/2020	04/01/2020	04/01/2020
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL HALLANDALE PHARMACY	1750 E HALLANDALE BEACH BLVD STE A	HALLANDALE BEACH	FL	33009-4611	02/26/2020	04/01/2020	04/01/2020	04/01/2020
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL MIRAMAR OUTPATIENT PHARMACY	1951 SW 172ND AVE STE 107	MIRAMAR	FL	33029-5613	02/26/2020	04/01/2020	04/01/2020	04/01/2020
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL REGIONAL OUTPATIENT PHARMACY	1150 N 35TH AVE STE 105	HOLLYWOOD	FL	33021	02/26/2020	04/01/2020	04/01/2020	04/01/2020
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL WEST OUTPATIENT PHARMACY	601 N FLAMINGO RD STE 110	PEMBROKE PINES	FL	33028-1007	02/26/2020	04/01/2020	04/01/2020	04/01/2020
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL SPECIALTY PHARMACY	9571 PREMIER PKWY	MIRAMAR	FL	33025-3206	02/26/2020	04/01/2020	04/01/2020	04/01/2020
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL HOME INFUSION	9579 PREMIER PKWY	MIRAMAR	FL	33025-3206	02/26/2020	04/01/2020	04/01/2020	04/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH100281A	Child	DSH	MEMORIAL HOSPITAL WEST	MCI WEST BCC INFUS 3	12235 Pines Blvd.	PEMBROKE PINES	FL	Active
DSH100281B	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST CANCER CENTER	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281C	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST EMERGENCY DEPT. AND MINOR CARE	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281D	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST OUTPATIENT CENTER	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281E	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST OUTPATIENT SURGERY	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281F	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST RADIOLOGY	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281G	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST CARDIAC CATHETERIZATION	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281H	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST ENDOSCOPY	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281I	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL WEST LDR	703 N. FLAMINGO RD.	PEMBROKE PINES	FL	Terminated
DSH100281J	Child	DSH	MEMORIAL HOSPITAL WEST	MEMORIAL CANCER INSTITUTE, WEST	12235 Pines Blvd.	PEMBROKE PINES	FL	Active
DSH100281K	Child	DSH	MEMORIAL HOSPITAL WEST	MCI Physicians MHW	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281L	Child	DSH	MEMORIAL HOSPITAL WEST	MCI Infusion MHW	Memorial Hospital West 3West Nursing Unit	Pembroke Pines	FL	Active
DSH100281M	Child	DSH	MEMORIAL HOSPITAL WEST	MCI WEST CYBERKNIFE	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281N	Child	DSH	MEMORIAL HOSPITAL WEST	MCI WEST RADIATION ONC	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281P	Child	DSH	MEMORIAL HOSPITAL WEST	Moffitt Physicians/Oncology	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281Q	Child	DSH	MEMORIAL HOSPITAL WEST	Breast Oncology Physicians MHW / Oncology	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281R	Child	DSH	MEMORIAL HOSPITAL WEST	Memorial Primary Care / West Miramar	10910 Pembroke Road	Miramar	FL	Active
DSH100281S	Child	DSH	MEMORIAL HOSPITAL WEST	Moffitt Physicians - Oncology	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281T	Child	DSH	MEMORIAL HOSPITAL WEST	Memorial Primary Care Silver Lakes Practice	17786 SW 2nd Street	Pembroke Pines	FL	Active
DSH100281U	Child	DSH	MEMORIAL HOSPITAL WEST	Memorial Primary Care - Monarch Lakes	12781 Miramar Parkway	Miramar	FL	Active
DSH100281V	Child	DSH	MEMORIAL HOSPITAL WEST	MCI West Infusion 4	12235 Pines Blvd.	Pembroke Pines	FL	Active
DSH100281W	Child	DSH	MEMORIAL HOSPITAL WEST	Women's Imaging Center - Women's Imaging Center	603 N. Flamingo Rd	Pembroke Pines	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 4:14:51 PM	8/12/2024 1:21:04 PM	8/12/2024 1:21 PM
Contacts	Authorizing Official	Update	Profile Change Request	STUCZYNSKI, JOSEPH CEO Memorial Hospital Miramar 9548838842	STUCZYNSKI, JOSEPH CEO Memorial Hospital West 9548446871	6/5/2024 1:31 PM
Addresses	Shipping Address	Delete	Change Request	Memorial Cancer Institute-West Attn: Pharmacy 801 North Flamingo Road Pembroke Pines, FL 33028		1/31/2024 7:01 AM
Addresses	Shipping Address	Insert	Change Request		South Broward Hospital District/ Memorial Cancer institute at Memorial Hospital West 12235 Pines Blvd Suite 4201 Pembroke Pines, FL 33036	1/31/2024 7:01 AM
Addresses	Main Address	Update	Change Request	603 N. FLAMINGO RD SUITE 157 PEMBROKE PINES, FL 33028	12235 Pines Blvd. PEMBROKE PINES, FL 33026	1/31/2024 7:01 AM
Details	Entity Subname	Update	Change Request	Memorial Breast Cancer Center / West	MCI WEST BCC INFUS 3	1/31/2024 7:01 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 10:16:55 AM	8/18/2023 4:14:51 PM	8/18/2023 4:14 PM
Contacts	Authorizing Official	Update	Change Request	Guerrier, Vedner CEO Memorial Hopsital West 9545384810	STUCZYNSKI, JOSEPH CEO Memorial Hospital Miramar 9548838842	6/20/2023 2:19 PM
Addresses	Shipping Address	Insert	Change Request		Memorial Cancer Institute-West Attn: Pharmacy 801 North Flamingo Road Pembroke Pines, FL 33028	9/19/2022 10:57 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 3:53:55 PM	8/24/2022 10:16:55 AM	8/24/2022 10:16 AM
Contacts	Authorizing Official	Update	Change Request	CARPENTER, LEAH CEO Memorial Healthcare System 9548447500	Guerrier, Vedner CEO Memorial Hopsital West 9545384810	1/13/2022 7:14 AM
Details	Last Recertification Date	Update	Recertification	8/24/2020 3:18:06 PM	8/19/2021 3:53:55 PM	8/19/2021 3:53 PM
Contacts	Primary Contact	Update	Profile Change Request	Soto, Alexsandra 340B Program Manager Memorial Healthcare System 9542761771	Soto, Alexsandra Director, 340B Program Memorial Healthcare System 9542761771	2/9/2021 11:00 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	99831031 (CO)		1/11/2021 9:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	596014973002 (IL)		1/11/2021 9:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	02064491 (NY)		1/11/2021 9:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2258480 (OH)		1/11/2021 9:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1002813 (VA)		1/11/2021 9:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0539395 (DC)		1/11/2021 9:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0103026000 (WV)		1/11/2021 9:30 AM
Medicaid Billing	NPI: State	Update	Recertification		FL	8/24/2020 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 9:20:38 AM	8/24/2020 3:18:06 PM	8/24/2020 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 12:59:11 PM	8/26/2019 9:20:38 AM	8/26/2019 9:20 AM
Contacts	Primary Contact	Update	Change Request	Barrios, Cherita Dawn 340B Quality Assurance Specialist Memorial Healthcare System 9542769871	Soto, Alexsandra 340B Program Manager Memorial Healthcare System 9542761771	1/30/2019 2:56 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 4:37:40 PM	8/16/2018 12:59:11 PM	8/16/2018 12:59 PM
Contacts	Primary Contact	Update	Change Request	Marcelin, Halena Leah 340B Program Manager Memorial Healthcare System 9542653212	Barrios, Cherita Dawn 340B Quality Assurance Specialist Memorial Healthcare System 9542769871	7/19/2018 8:46 AM
Addresses	Billing Address	Insert	Recertification		Memorial Healthcare System PO Box 269001 Attn: Accounts Payable Pembroke Pines, FL 33026	12/4/2017 4:37 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	12/4/2017 4:37:40 PM	12/4/2017 4:37 PM
Details	Entity Subname	Update	Recertification	MEMORIAL BREAST CANCER CENTER, WEST	Memorial Breast Cancer Center / West	12/4/2017 4:37 PM
Contacts	Authorizing Official	Update		CARPENTER, LEAH CEO 9548447500	CARPENTER, LEAH CEO Memorial Healthcare System 9548447500	10/23/2017 4:05 PM
Contacts	Primary Contact	Update		Marcelin, Halena Leah 340B Program Manager 9542653212	Marcelin, Halena Leah 340B Program Manager Memorial Healthcare System 9542653212	10/11/2017 2:55 PM
Contacts	Primary Contact	Insert			Marcelin, Halena Leah 340B Program Manager 9542653212	7/25/2017 7:26 AM
Contacts	Authorizing Official	Update		BUSSELL, WALTER CFO 9544365000-7109	CARPENTER, LEAH CEO 9548447500	7/18/2017 5:04 PM
Addresses	Main Address	Insert			603 N. FLAMINGO RD SUITE 157 PEMBROKE PINES, FL 33028	12/9/2016 10:58 AM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 4:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			010252100	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			FL	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			99831031	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			CO	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			596014973002	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			IL	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			02064491	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			NY	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			2258480	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			OH	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			1002813	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			VA	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			0539395	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			DC	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			0103026000	4/22/2016 10:33 AM
Medicaid Billing	Medicaid: State	Insert			WV	4/22/2016 10:33 AM
Medicaid Billing	NPI: Number	Insert			1134102080	4/22/2016 10:33 AM
Details	Entity Name	Update		SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	MEMORIAL HOSPITAL WEST	4/22/2016 10:33 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 5:13 PM
Details	Last Recertification Date	Update		8/27/2013 9:15:56 AM	8/7/2014 12:00:00 AM	8/7/2014 8:03 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/27/2013 9:15:56 AM	8/27/2013 9:15 AM
Details	Entity Subname	Update		MEMORIAL WEST BREAST CENTER	MEMORIAL BREAST CANCER CENTER, WEST	4/15/2013 6:57 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/4/2012 8:43 AM
Contacts	Authorizing Official	Insert			BUSSELL, WALTER CFO 9544365000-7109	6/11/2010 11:01 AM
Details	Last Recertification Date	Insert				12/11/2007 4:06 PM
Details	Grant Number	Insert				12/11/2007 4:06 PM
Details	340B ID	Insert			DSH100281A	12/11/2007 4:06 PM
Details	Is Authorizing Official EHB Data	Insert				12/11/2007 4:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert				12/11/2007 4:06 PM
Details	Medicare Provider Number	Insert			100281	12/11/2007 4:06 PM
Details	Entity Name	Insert			SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL WEST	12/11/2007 4:06 PM
Details	Program Code	Insert			DSH	12/11/2007 4:06 PM
Details	Entity Subname	Insert			MEMORIAL WEST BREAST CENTER	12/11/2007 4:06 PM
Dates	Participating Approval Date	Insert			12/12/2007 12:00:00 AM	12/11/2007 4:06 PM
Details	State	Insert			Active	12/11/2007 4:06 PM
Dates	Registration Date	Insert			12/11/2007 12:00:00 AM	12/11/2007 4:06 PM
Dates	Signed By Date	Insert			12/10/2007 12:00:00 AM	12/11/2007 4:06 PM
Dates	Start Date	Insert			1/1/2008 12:00:00 AM	12/11/2007 4:06 PM
Terminations	Termination Comments	Insert				12/11/2007 4:06 PM
Terminations	Termination Date	Insert				12/11/2007 4:06 PM
Terminations	Termination Effective Date	Insert				12/11/2007 4:06 PM
Terminations	Termination Reason	Insert				12/11/2007 4:06 PM
Details	Comments Public	Insert			4/7/2010- AMDP- NETWORK- SOUTH BROWARD HOSPITAL DISTRICT; 4/7/08-REVISED TO SHIP-TO ADDRESS (WAS 603 N. FLAMINGO RD.)	12/11/2007 4:06 PM