Contract Pharmacy Details

SOUTH BROWARD HOSPITAL DISTRICT
DSH100038BA MEMORIAL REGIONAL HOSPITAL

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 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

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

340B Drug Pricing Program Database