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BALAJI PHARMA LLC
STD336121 Doctor's Goodwill Foundation Inc
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Covered Entity Details
Entity Name
Doctor's Goodwill Foundation Inc
Subdivision Name
Forest Hills
Type
Sexually Transmitted Diseases
340B ID
STD336121
Entity Address
116 Bougainvilea Ave
Tampa, FL 33612
Grant Number
H25PS005131
Participating Start Date
8/21/2020
Last Recertification Date
5/10/2021
Entity Termination Date
4/1/2022
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
8/5/2020
Contract Begin Date
8/21/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
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
7/2/2020
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