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SOUTH BROWARD HOSPITAL DISTRICT
DSH100230D MEMORIAL HOSPITAL PEMBROKE
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL PEMBROKE
Subdivision Name
Pembroke 24/7 Care Center / Radiology-Diagnostic PUCC
Type
Disproportionate Share Hospital
340B ID
DSH100230D
Entity Address
801 South Douglas Road
Pembroke Pines, FL 33025
Medicare Provider Number
100230
Outpatient Facility Provider Number
Participating Start Date
1/1/2016
Last Recertification Date
8/13/2024
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
Mark Doyle, CEO
(954) 883-8401
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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