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PUBLIX PHARMACY #0402
DSH100285 MEMORIAL HOSPITAL MIRAMAR
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL MIRAMAR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100285
Entity Address
1901 SW 172ND AVENUE
Miramar, FL 33029
Medicare Provider Number
100285
Participating Start Date
10/1/2006
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #0402
Pharmacy Address
1400 E HALLANDALE BEACH BLVD
HALLANDALE BEACH, FL 33009
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
JOSEPH STUCZYNSKI, CEO
(954) 844-6871
Contract Pharmacy Representative
Publix
Amin Mrugesh, 340B Program Manager
(863) 688-1188 Ext: 52388
Signed By Date
1/17/2023
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