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SOUTH BROWARD HOSPITAL DISTRICT
DSH100281N MEMORIAL HOSPITAL WEST
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL WEST
Subdivision Name
MCI WEST RADIATION ONC
Type
Disproportionate Share Hospital
340B ID
DSH100281N
Entity Address
12235 Pines Blvd.
Pembroke Pines, FL 33026
Medicare Provider Number
100281
Outpatient Facility Provider Number
Participating Start Date
4/1/2016
Last Recertification Date
8/12/2024
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
2/26/2020
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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