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SOUTH BROWARD HOSPITAL DISTRICT
DSH100038BE MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Breast Oncology Center Infusion MRH
Type
Disproportionate Share Hospital
340B ID
DSH100038BE
Entity Address
1150 North 35th Avenue
Suite #170
Hollywood, FL 33021
Medicare Provider Number
100038
Outpatient Facility Provider Number
Participating Start Date
1/1/2016
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
2/25/2020
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
2/25/2020
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