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XINIM-CORP
STD32132 Doctor's Goodwill Foundation Inc
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Covered Entity Details
Entity Name
Doctor's Goodwill Foundation Inc
Subdivision Name
Medfast Edgewater
Type
Sexually Transmitted Diseases
340B ID
STD32132
Entity Address
1000 S Ridgewood Ave
Edgewater, FL 32132
Grant Number
H25PS005131
Participating Start Date
4/1/2020
Last Recertification Date
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
XINIM-CORP
Pharmacy Address
HOLLY HILL PHARMACY
1702 RIDGEWOOD AVE STE C-G
HOLLY HILL, FL 32117
Pharmacy Comments
Contract Details
Approval Date
3/2/2020
Contract Begin Date
4/1/2020
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
XINIM-Corp Holly Hill Pharmacy
Tom Hill, Pharmicist in Charge
(386) 677-7377
Signed By Date
3/2/2020
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