Provider Demographics
NPI:1649601964
Name:SOUTH BROWARD HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SOUTH BROWARD HOSPITAL DISTRICT
Other - Org Name:MEMORIAL WEST OUTPATIENT 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:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-265-2995
Mailing Address - Street 1:601 NORTH FLAMINGO ROAD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1006
Mailing Address - Country:US
Mailing Address - Phone:954-844-6280
Mailing Address - Fax:954-844-6286
Practice Address - Street 1:601 NORTH FLAMINGO ROAD
Practice Address - Street 2:SUITE 110
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1006
Practice Address - Country:US
Practice Address - Phone:954-844-6280
Practice Address - Fax:954-844-6286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH166583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010978900Medicaid