Covered Entity Details

DSH100038BJ MEMORIAL REGIONAL HOSPITAL (Terminated) - information as of 4/25/2025 5:39:06 PM

Main Details

Name

MEMORIAL REGIONAL HOSPITAL

Subdivision Name

Home Health Agency (Home Health Aide)

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100038BJ

Medicare Provider Number

100038

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/12/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/8/2016

Last Recertification Date

8/30/2021

Termination Date
Termination Reason

10/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Memorial Healthcare System
Peter Powers, CEO, Memorial Regional Hospital
(954) 265-5814

Primary Contact

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

Addresses

Street Address

7029 Taft Street
Hollywood, FL 33024

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
No records to display.

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	10020000,650009900	1780667923

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL HALLANDALE PHARMACY	1750 E HALLANDALE BEACH BLVD STE A	HALLANDALE BEACH	FL	33009-4611	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL REGIONAL HOSPITAL PRIMARY CARE	4105 PEMBROKE RD.	HOLLYWOOD	FL	33021	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL REGIONAL OUTPATIENT PHARMACY	1150 N 35TH AVE STE 105	HOLLYWOOD	FL	33021	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL SPECIALTY PHARMACY	9571 PREMIER PKWY	MIRAMAR	FL	33025-3206	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL HOME INFUSION	9579 PREMIER PKWY	MIRAMAR	FL	33025-3206	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL MIRAMAR OUTPATIENT PHARMACY	1951 SW 172ND AVE STE 107	MIRAMAR	FL	33029-5613	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022
Contract Detail	SOUTH BROWARD HOSPITAL DISTRICT	MEMORIAL WEST OUTPATIENT PHARMACY	601 N FLAMINGO RD STE 110	PEMBROKE PINES	FL	33028-1007	02/25/2020	04/01/2020	04/01/2020	10/01/2022	10/01/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH100038A	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care Clinic- Hollywood	4105 PEMBROKE ROAD	HOLLYWOOD	FL	Active
DSH100038AA	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Outpatient Surgery: Recovery Room	3600 Washington Street	Hollywood	FL	Active
DSH100038AB	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Outpatient Surgery: Operating Room	3501 Johnson Street	HOLLYWOOD	FL	Terminated
DSH100038AC	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Outpatient Observation	3600 Washington Street	HOLLYWOOD	FL	Active
DSH100038AD	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Emergency Room	3600 Washington Street	HOLLYWOOD	FL	Active
DSH100038AE	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Wound Care Center	3600 Washington Street	HOLLYWOOD	FL	Terminated
DSH100038AF	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Diabetes & Nutrition Center	3600 Washington Street	HOLLYWOOD	FL	Terminated
DSH100038AG	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Sleep Lab	3600 Washington Street	HOLLYWOOD	FL	Terminated
DSH100038AH	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Outpatient Services 609041	3600 Washington Street	HOLLYWOOD	FL	Active
DSH100038AJ	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Endoscopy Suite	3600 Washington Street	Hollywood	FL	Active
DSH100038AK	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Dialysis	3600 Washington Street	Hollywood	FL	Active
DSH100038AL	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Electrocardiology	3600 Washington Street	Hollywood	FL	Active
DSH100038AM	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Respiratory Therapy	3600 Washington Street	Hollywood	FL	Active
DSH100038AN	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / MRI	3600 Washington Street	Hollywood	FL	Active
DSH100038AP	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / C.T. Scan	3600 Washington Street	Hollywood	FL	Active
DSH100038AQ	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Diagnostic Ultrasound	3600 Washington Street	Hollywood	FL	Active
DSH100038AR	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Nuclear Medicine	3600 Washington Street	Hollywood	FL	Active
DSH100038AS	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Interventional Radiology	3600 Washington Street	Hollywood	FL	Active
DSH100038AT	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Diagnostic Radiology	3600 Washington Street	Hollywood	FL	Active
DSH100038AU	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Breast Center	3600 Washington Street	Hollywood	FL	Active
DSH100038AV	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Outpatient Surgery: Anesthesiology-Operating	3600 Washington Street	Hollywood	FL	Active
DSH100038AW	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care Gulfstream	2056 Scott Street	Hollywood	FL	Active
DSH100038AX	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Outpatient Surgery: Operating Room	3600 Washington Street	Hollywood	FL	Active
DSH100038AY	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care - Hallandale Beach	1750 East Hallandale Beach Blvd.	Hallandale Beach	FL	Active
DSH100038AZ	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	JDCH Pediatric Ambulatory Services (Clinic)	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038B	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care - East Hollywood	3700 Johnson Street	HOLLYWOOD	FL	Active
DSH100038BA	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care Pediatric Mobile Van	3600 Washington Street	Hollywood	FL	Terminated
DSH100038BB	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care Adult Clinic	4105 Pembroke Road	Hollywood	FL	Active
DSH100038BC	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Pediatric Outpatient Rehab / Outpatient Rehab	300 Hollywood Way	Hollywood	FL	Active
DSH100038BD	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MRHS Outpatient Rehabilitation	300 Hollywood Way	Hollywood	FL	Active
DSH100038BE	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Breast Oncology Center Infusion MRH	1150 North 35th Avenue	Hollywood	FL	Active
DSH100038BF	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MCI Infusion Hallandale Beach	1750 E Hallandale Beach Blvd	Hallandale	FL	Active
DSH100038BG	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MCI Phycians Hallandale Beach MRH	1750 E HALLANDALE BEACH BLVD	Hallandale Beach	FL	Active
DSH100038BH	Child	DSH	MEMORIAL REGIONAL HOSPITAL	JDCH - Outpatient Surgery: Recovery Room	3501 Johnson Street	Hollywood	FL	Terminated
DSH100038BJ	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Home Health Agency (Home Health Aide)	7029 Taft Street	Hollywood	FL	Terminated
DSH100038BK	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Home Health Agency / Skilled Nursing	7029 Taft Street	Hollywood	FL	Terminated
DSH100038BL	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Home Health Agency / Social Services	7029 Taft Street	Hollywood	FL	Terminated
DSH100038BM	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Home Health Agency / Speech Therapy	7029 Taft Street	Hollywood	FL	Terminated
DSH100038BN	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Home Health Agency / Physical Therapy	7029 Taft Street	Hollywood	FL	Terminated
DSH100038BP	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Home Health Agency / Occupational Therapy	7029 Taft Street	Hollywood	FL	Terminated
DSH100038BQ	Child	DSH	MEMORIAL REGIONAL HOSPITAL	South Broward Community Health Services / OB/GYN	4105 Pembroke Road	Hollywood	FL	Active
DSH100038BR	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Outpatient Services at MRHS - Inpatient Rehabilitation	3600 Washington Street	Hollywood	FL	Active
DSH100038BS	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MCI Physicians MRH Suite / Oncology	1150 N 35th Ave	Hollywood	FL	Active
DSH100038BT	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care Adult Mobile Van	3600 Washington Street	Hollywood	FL	Terminated
DSH100038BU	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Regional Hospital South / Outpatient Services 606041	3600 Washington Street	Hollywood	FL	Terminated
DSH100038BV	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Adult Kidney Transplant - Adult Kidney Transplant	1150 N 35TH AVENUE	Miami	FL	Active
DSH100038BW	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Pediatric Kidney Transplant - Pediatric Kidney Transplant	1150 N 35TH AVENUE	Pembroke Pines	FL	Active
DSH100038BX	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Wellington-Imaging - Imaging	3377 South State Road 7	Wellington	FL	Terminated
DSH100038BY	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Cypress Creek OP Rehab - Rehab	2122 NW 62nd Street	Ft. Lauderdale	FL	Active
DSH100038BZ	Child	DSH	MEMORIAL REGIONAL HOSPITAL	JDCH Pediatric Transplant Department - Pediatric Heart Transplant	1150 N 35TH AVENUE	Hollywood	FL	Active
DSH100038C	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Primary Care Clinic- Dania Beach	140A South Federal Highway	Dania Beach	FL	Active
DSH100038CA	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Echocardiography - MRHS Echocardiography	3600 Washington Street	Hollywood	FL	Active
DSH100038CB	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MEMORIAL HEALTHCARE SYSTEM SICKLE C - Sickle Cell	3700 Johnson Street	HOLLYWOOD	FL	Active
DSH100038CC	Child	DSH	MEMORIAL REGIONAL HOSPITAL	BH Mind Body Wellness - Behavioral Health	5595 S University Drive	Davie	FL	Active
DSH100038D	Child	DSH	MEMORIAL REGIONAL HOSPITAL	BREAST CANCER CENTER AT MEMORIAL REGIONAL HOSPITAL / BREAST ONC PHYSICIANS	1150 NORTH 35TH AVE	HOLLYWOOD	FL	Active
DSH100038E	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	SOUTH CAMPUS	3600 WASHINGTON STREET	HOLLYWOOD	FL	Terminated
DSH100038F	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	MEMORIAL CANCER INSTITUTE	20801 BISCAYNE BLVD	AVENTURA	FL	Terminated
DSH100038G	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MCI Infusion MRH	1150 North 35th AVE	HOLLYWOOD	FL	Active
DSH100038H	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	South Broward Hospital District DBA Joe DiMaggio Children's Hospital	1005 Joe DiMaggio Dr.	Hollywood	FL	Terminated
DSH100038J	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Center for Behavioral Health & SHARE / Outpatient Behavioral Health	5595 South University Drive	Davie	FL	Active
DSH100038K	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Memorial Home Health Services	7369 Sheridan Street, Suite 101	Hollywood	FL	Terminated
DSH100038L	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Pediatric Observation	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038M	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Endoscopy	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038N	Child	DSH	MEMORIAL REGIONAL HOSPITAL	Outpatient Therapy - Coral Springs	5830 Coral Ridge Drive	Coral Springs	FL	Active
DSH100038P	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Outpatient Rehab - MRH	300 Hollywood Way	Hollywood	FL	Terminated
DSH100038Q	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	JDCH Respiratory Therapy	3501 Johnson Street	Hollywood	FL	Terminated
DSH100038R	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	JDCH Respiratory Therapy	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038S	Child	DSH	MEMORIAL REGIONAL HOSPITAL	MRI - Coral Springs	5830 Coral Ridge Drive	Coral Springs	FL	Active
DSH100038T	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	MRI	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038U	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	CT Scan	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038V	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	JDCH Peds Hem/Onc OP	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038W	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Diagnostic Ultrasound	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038X	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Nuclear Medicine	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038Y	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	Diagnostic Radiology	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated
DSH100038Z	Child	DSH	SOUTH BROWARD HOSPITAL DISTRICT DBA MEMORIAL REGIONAL HOSPITAL	JDCH - Anestheiology Operating (Outpatient Surgery)	1005 Joe DiMaggio Drive	Hollywood	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		9/30/2022 12:00:00 AM	8/24/2022 12:51 PM
Details	State	Update	Recertification	Active	To Be Terminated	8/24/2022 12:51 PM
Terminations	Termination Date	Update	Recertification		10/1/2022 12:00:00 AM	8/24/2022 12:51 PM
Terminations	Termination Effective Date	Update	Recertification		10/1/2022 12:00:00 AM	8/24/2022 12:51 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	8/24/2022 12:51 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 2:17:33 PM	8/30/2021 1:03:01 PM	8/30/2021 1:03 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
Addresses	Main Address	Update	Change Request	7369 Sheridan Street Suite 101 Hollywood, FL 33024	7029 Taft Street Hollywood, FL 33024	10/23/2020 9:21 AM
Medicaid Billing	NPI: State	Update	Recertification		FL	8/25/2020 2:17 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 1:18:15 PM	8/25/2020 2:17:33 PM	8/25/2020 2:17 PM
Contacts	Authorizing Official	Update	Change Request	Frum, Judy Lynne COO Memorial Healthcare 9542654105	Powers, Peter CEO, Memorial Regional Hospital Memorial Healthcare System 9542655814	6/11/2020 8:41 AM
Contacts	Authorizing Official	Update	Change Request	ROSS, ZEFF CEO Memorial Healthcare System 9542655814	Frum, Judy Lynne COO Memorial Healthcare 9542654105	12/20/2019 10:30 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 10:38:55 AM	8/20/2019 1:18:15 PM	8/20/2019 1:18 PM
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	1/28/2019 1:54 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 9:14:01 AM	8/16/2018 10:38:55 AM	8/16/2018 10:38 AM
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 4:58 PM
Addresses	Billing Address	Insert	Recertification		Memorial Healthcare System PO Box 269001 Attn: Accounts Payable Pembroke Pines, FL 33026	12/4/2017 9:14 AM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	12/4/2017 9:14:01 AM	12/4/2017 9:14 AM
Contacts	Authorizing Official	Update		ROSS, ZEFF CEO 9542655814	ROSS, ZEFF CEO Memorial Healthcare System 9542655814	10/16/2017 12:07 PM
Contacts	Signed By	Update		ROSS, ZEFF CEO 9542655814	ROSS, ZEFF CEO Memorial Healthcare System 9542655814	10/16/2017 12:07 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	Insert			ROSS, ZEFF CEO 9542655814	7/25/2017 7:26 AM
Contacts	Signed By	Insert			ROSS, ZEFF CEO 9542655814	7/25/2017 7:26 AM
Addresses	Main Address	Insert			7369 Sheridan Street Suite 101 Hollywood, FL 33024	11/1/2016 3:25 PM
Details	Last Recertification Date	Update			8/12/2016 12:00:00 AM	8/12/2016 2:46 PM
Dates	Participating Approval Date	Update			3/8/2016 12:00:00 AM	3/8/2016 12:14 PM
Details	State	Update		Pending	Active	3/8/2016 12:14 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/8/2016 12:14 PM
Details	Entity Subname	Update		Home Health Agency (Home Health Aide) / Home Health Aide	Home Health Agency (Home Health Aide)	3/2/2016 12:34 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57201	DSH100038BJ	2/23/2016 3:39 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57201	1/12/2016 12:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/12/2016 12:17 PM
Medicaid Billing	Medicaid: Number	Insert			10020000	1/12/2016 12:17 PM
Medicaid Billing	Medicaid: State	Insert			FL	1/12/2016 12:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/12/2016 12:17 PM
Medicaid Billing	Medicaid: Number	Insert			650009900	1/12/2016 12:17 PM
Medicaid Billing	Medicaid: State	Insert			FL	1/12/2016 12:17 PM
Medicaid Billing	NPI: Number	Insert			1780667923	1/12/2016 12:17 PM
Details	Last Recertification Date	Insert				1/12/2016 12:17 PM
Details	Grant Number	Insert				1/12/2016 12:17 PM
Details	340B ID	Insert				1/12/2016 12:17 PM
Details	Is Authorizing Official EHB Data	Insert				1/12/2016 12:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2016 12:17 PM
Details	Medicare Provider Number	Insert			100038	1/12/2016 12:17 PM
Details	Entity Name	Insert			MEMORIAL REGIONAL HOSPITAL	1/12/2016 12:17 PM
Details	Program Code	Insert			DSH	1/12/2016 12:17 PM
Details	Entity Subname	Insert			Home Health Agency (Home Health Aide) / Home Health Aide	1/12/2016 12:17 PM
Dates	Participating Approval Date	Insert				1/12/2016 12:17 PM
Details	State	Insert			Pending	1/12/2016 12:17 PM
Dates	Registration Date	Insert			1/12/2016 12:00:00 AM	1/12/2016 12:17 PM
Dates	Signed By Date	Insert			1/12/2016 12:00:00 AM	1/12/2016 12:17 PM
Dates	Start Date	Insert				1/12/2016 12:17 PM
Terminations	Termination Comments	Insert				1/12/2016 12:17 PM
Terminations	Termination Date	Insert				1/12/2016 12:17 PM
Terminations	Termination Effective Date	Insert				1/12/2016 12:17 PM
Terminations	Termination Reason	Insert				1/12/2016 12:17 PM