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SOUTH BROWARD HOSPITAL DISTRICT
DSH100038AG MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Memorial Regional Hospital South / Sleep Lab
Type
Disproportionate Share Hospital
340B ID
DSH100038AG
Entity Address
3600 Washington Street
HOLLYWOOD, FL 33021
Medicare Provider Number
100038
Outpatient Facility Provider Number
Participating Start Date
7/1/2014
Last Recertification Date
8/25/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
SOUTH BROWARD HOSPITAL DISTRICT
Pharmacy Address
MEMORIAL REGIONAL OUTPATIENT PHARMACY
1150 N 35TH AVE STE 105
HOLLYWOOD, FL 33021
Pharmacy Comments
Contract Details
Approval Date
2/24/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
4/1/2020
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Judy Lynne Frum, COO
(954) 265-4105
Contract Pharmacy Representative
Memorial Healthcare System
Dorinda Segovia, Vice President of Pharmacy Services
(954) 276-1770
Signed By Date
2/24/2020
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