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COMMCARE PHARMACY-WPB, LLC
DSH100281 MEMORIAL HOSPITAL WEST
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL WEST
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100281
Entity Address
703 NORTH FLAMINGO ROAD
PEMBROKE PINES, FL 33028
Medicare Provider Number
100281
Participating Start Date
10/11/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
COMMCARE PHARMACY-WPB, LLC
Pharmacy Address
1689 FORUM PLACE
WEST PALM BEACH, FL 33401
Pharmacy Comments
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/11/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KENNON C. HETLAGE, ADMINISTRATOR
(954) 844-7500
Contract Pharmacy Representative
Vic Simianu, Manager, Special Projects
(954) 332-6150
Signed By Date
4/15/2014
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