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LORDONI DISCOUNT PHARMACY
STD32907 Doctor's Goodwill Foundation
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Covered Entity Details
Entity Name
Doctor's Goodwill Foundation
Subdivision Name
Omni - Palm Bay Clinic
Type
Sexually Transmitted Diseases
340B ID
STD32907
Entity Address
6100 Minton Rd. NW
104
Palm Bay, FL 32907
Grant Number
5H25PS004342
Participating Start Date
1/1/2020
Last Recertification Date
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
LORDONI DISCOUNT PHARMACY
Pharmacy Address
LORDONI DISCOUNT PHARMACY
6300 N WICKHAM RD STE 126
MELBOURNE, FL 32940-3294
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
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
Lordoni Discount Pharmacy
Olu Oni, Pharmacist in Charge
(321) 610-3117
Signed By Date
1/15/2020
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