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SOUTH BROWARD HOSPITAL DISTRICT
DSH100038BL MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Home Health Agency / Social Services
Type
Disproportionate Share Hospital
340B ID
DSH100038BL
Entity Address
7029 Taft Street
Hollywood, FL 33024
Medicare Provider Number
100038
Outpatient Facility Provider Number
Participating Start Date
4/1/2016
Last Recertification Date
8/30/2021
Entity Termination Date
10/1/2022
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
10/1/2022
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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