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WAL-MART PHARMACY 10-5315
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
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/4/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/25/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOSEPH STUCZYNSKI, CEO
(954) 844-6871
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/4/2023
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