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WAL-MART PHARMACY 10-3625
DSH100281 MEMORIAL HOSPITAL WEST
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL WEST
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100281
Entity Address
703 NORTH FLAMINGO ROAD
PEMBROKE PINES, FL 33028
Medicare Provider Number
100281
Participating Start Date
10/11/2005
Last Recertification Date
8/12/2024
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
4/6/2023
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
Vedner Guerrier, CEO
(954) 538-4810
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/6/2023
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