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BENZER FL3 LLC
STD33321 Independent Medical Group, LLC
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Covered Entity Details
Entity Name
Independent Medical Group, LLC
Subdivision Name
Plantation
Type
Sexually Transmitted Diseases
340B ID
STD33321
Entity Address
4101 S Hospital Drive
2
Plantation, FL 33317
Grant Number
NH25PS004342-04-01
Participating Start Date
9/19/2019
Last Recertification Date
5/9/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
BENZER FL3 LLC
Pharmacy Address
ELITE PHARMACY
901 W INDIANTOWN RD STE 23
JUPITER, FL 33458
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
4/27/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Steve Vixamar, COO
(954) 529-1178
Contract Pharmacy Representative
Benzer fl 3 llc
Tejas Patel, Pharmacist
(561) 529-2851
Signed By Date
4/14/2020
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