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PUBLIX PHARMACY #0509
DSH100038 MEMORIAL REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100038
Entity Address
3501 Johnson Street
Hollywood, FL 33021
Medicare Provider Number
100038
Participating Start Date
10/1/2002
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #0509
Pharmacy Address
12500 W. SUNRISE BLVD
SUNRISE, FL 33323-2987
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/28/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peter Powers, CEO, Memorial Regional Hospital
(954) 265-5814
Contract Pharmacy Representative
Publix
Amin Mrugesh, 340B Program Manager
(863) 688-1188 Ext: 52388
Signed By Date
1/17/2023
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