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SOUTH BROWARD HOSPITAL DISTRICT
DSH100285A MEMORIAL HOSPITAL MIRAMAR
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL MIRAMAR
Subdivision Name
MOB II - OUTPATIENT CENTER
Type
Disproportionate Share Hospital
340B ID
DSH100285A
Entity Address
1971 SW 172nd Avenue
Miramar, FL 33029
Medicare Provider Number
100285
Outpatient Facility Provider Number
Participating Start Date
4/1/2023
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
4/3/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JOSEPH STUCZYNSKI, CEO
(954) 844-6871
Contract Pharmacy Representative
Memorial Healthcare System
Dorinda Segovia, Vice President of Pharmacy Services
(954) 276-1770
Signed By Date
4/3/2023
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