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SEBASTIAN PHARMACY LLC
STD32826 Doctor's Goodwill Foundation
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Covered Entity Details
Entity Name
Doctor's Goodwill Foundation
Subdivision Name
Avalon Medical Clinic
Type
Sexually Transmitted Diseases
340B ID
STD32826
Entity Address
14807 East Colonial Dr.
112
Orlando, FL 32826
Grant Number
5H25PS004342
Participating Start Date
1/1/2020
Last Recertification Date
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
SEBASTIAN PHARMACY LLC
Pharmacy Address
DBA: SEBASTIAN DISCOUNT PHARMACY
13403 US HIGHWAY 1
SEBASTIAN, FL 32958-3756
Pharmacy Comments
Contract Details
Approval Date
12/3/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kantilal Bhalani, CEO
(321) 298-5531 Ext: 9414416212
Contract Pharmacy Representative
Sebastian Pharmacy, LLC
Alkesh Shastri, Manager
(772) 594-9292
Signed By Date
10/14/2019
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