Provider Demographics
NPI:1275864670
Name:SOUTH BROWARD HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SOUTH BROWARD HOSPITAL DISTRICT
Other - Org Name:MEMORIAL HALLANDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HETLAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-265-2995
Mailing Address - Street 1:1750 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4611
Mailing Address - Country:US
Mailing Address - Phone:954-276-9800
Mailing Address - Fax:954-456-2680
Practice Address - Street 1:1750 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4611
Practice Address - Country:US
Practice Address - Phone:954-276-9800
Practice Address - Fax:954-456-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FLPH243633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004668200Medicaid
2123984OtherPK
FL1045270007Medicare NSC