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SOUTH BROWARD HOSPITAL DISTRICT
DSH100038BW MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Memorial Pediatric Kidney Transplant - Pediatric Kidney Transplant
Type
Disproportionate Share Hospital
340B ID
DSH100038BW
Entity Address
1150 N 35TH AVENUE
Suite 445
Pembroke Pines
Pembroke Pines, FL 33026
Medicare Provider Number
100038
Outpatient Facility Provider Number
Participating Start Date
4/1/2021
Last Recertification Date
8/13/2024
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
3/9/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter Powers, CEO, Memorial Regional Hospital
(954) 265-5814
Contract Pharmacy Representative
Memorial Healthcare System
Dorinda Segovia, Vice President of Pharmacy Services
(954) 276-1770
Signed By Date
1/13/2021
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