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SOUTH BROWARD HOSPITAL DISTRICT
DSH100038BA MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Memorial Primary Care Pediatric Mobile Van
Type
Disproportionate Share Hospital
340B ID
DSH100038BA
Entity Address
3600 Washington Street
Hollywood, FL 33021
Medicare Provider Number
100038
Outpatient Facility Provider Number
Participating Start Date
1/1/2016
Last Recertification Date
8/25/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
SOUTH BROWARD HOSPITAL DISTRICT
Pharmacy Address
MEMORIAL SPECIALTY PHARMACY
9571 PREMIER PKWY
MIRAMAR, FL 33025-3206
Pharmacy Comments
Contract Details
Approval Date
2/25/2020
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
2/25/2020
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