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SOUTH BROWARD HOSPITAL DISTRICT
DSH100281S MEMORIAL HOSPITAL WEST
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL WEST
Subdivision Name
Moffitt Physicians - Oncology
Type
Disproportionate Share Hospital
340B ID
DSH100281S
Entity Address
12235 Pines Blvd.
Pembroke Pines, FL 33026
Medicare Provider Number
100281
Outpatient Facility Provider Number
Participating Start Date
1/1/2019
Last Recertification Date
8/12/2024
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
2/26/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
4/1/2020
Contract Comments
Contacts
Covered Entity Signing Official
LEAH CARPENTER, CEO
(954) 844-7500
Contract Pharmacy Representative
Memorial Healthcare System
Dorinda Segovia, Vice President of Pharmacy Services
(954) 276-1770
Signed By Date
2/26/2020
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