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SOUTH BROWARD HOSPITAL DISTRICT
DSH100038AW MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Memorial Primary Care Gulfstream
Type
Disproportionate Share Hospital
340B ID
DSH100038AW
Entity Address
2056 Scott Street
Hollywood, FL 33020
Medicare Provider Number
100038
Outpatient Facility Provider Number
Participating Start Date
1/1/2017
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
SOUTH BROWARD HOSPITAL DISTRICT
Pharmacy Address
MEMORIAL WEST OUTPATIENT PHARMACY
601 N FLAMINGO RD STE 110
PEMBROKE PINES, FL 33028-1007
Pharmacy Comments
Contract Details
Approval Date
2/24/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
4/1/2020
Contract Comments
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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