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WAL-MART PHARMACY 10-3625
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
WAL-MART PHARMACY 10-3625
Pharmacy Address
3001 NORTH STATE ROAD #7
LAUDERDALE LAKES, FL 33313
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
Peter Powers, CEO, Memorial Regional Hospital
(954) 265-5814
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/4/2023
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