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ANGELS PHARMACY III LLC
STD329402 Doctor's Goodwill Foundation
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Covered Entity Details
Entity Name
Doctor's Goodwill Foundation
Subdivision Name
Omni - Melbourne Clinic
Type
Sexually Transmitted Diseases
340B ID
STD329402
Entity Address
6300 N. Wickham Rd.
132A
Melbourne, FL 32940
Grant Number
5H25PS004342
Participating Start Date
1/1/2020
Last Recertification Date
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
ANGELS PHARMACY III LLC
Pharmacy Address
7455 S US HIGHWAY 1 STE A
TITUSVILLE, FL 32780
Pharmacy Comments
Contract Details
Approval Date
12/4/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kantilal Bhalani, CEO
(321) 298-5531 Ext: 9414416212
Contract Pharmacy Representative
Angel's Pharmacy I Inc.
Rajendra Patel, CEO
(407) 426-7000
Signed By Date
10/14/2019
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