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BALAJI PHARMA LLC
STD336112 Doctor's Goodwill Foundation Inc
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Covered Entity Details
Entity Name
Doctor's Goodwill Foundation Inc
Subdivision Name
Dr. NP - Hillsborough
Type
Sexually Transmitted Diseases
340B ID
STD336112
Entity Address
4543 S Manhattan Ave
103
Tampa, FL 33611
Grant Number
H25PS005131
Participating Start Date
7/1/2020
Last Recertification Date
5/3/2021
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
BALAJI PHARMA LLC
Pharmacy Address
D/B/A PALM PLAZA PHARMACY
162 N. PARSONS AVE.
BRANDON, FL 33510
Pharmacy Comments
Contract Details
Approval Date
5/21/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kantilal Bhalani, CEO
(321) 298-5531 Ext: 9414416212
Contract Pharmacy Representative
Palm Plaza Pharmacy
Dhwanit Sahita, Manager
(813) 689-7700
Signed By Date
5/21/2020
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