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SEBASTIAN PHARMACY 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
SEBASTIAN PHARMACY LLC
Pharmacy Address
DBA: SEBASTIAN DISCOUNT PHARMACY
13403 US HIGHWAY 1
SEBASTIAN, FL 32958-3756
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
Sebastian Pharmacy, LLC
Alkesh Shastri, Manager
(772) 594-9292
Signed By Date
10/15/2019
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