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BENZER FL3 LLC
STD333052 Independent Medical Group, LLC
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Covered Entity Details
Entity Name
Independent Medical Group, LLC
Subdivision Name
Fort Lauderdale
Type
Sexually Transmitted Diseases
340B ID
STD333052
Entity Address
3800 Inverrary Blve
109
Fort Lauderdale, FL 33319
Grant Number
NH25PS004342-04-01
Participating Start Date
9/17/2019
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
4/28/2020
Contract Begin Date
4/28/2020
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
4/28/2020
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