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EZ RX HALLANDALE LLC
STD330121 Doctors United Group Inc
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Covered Entity Details
Entity Name
Doctors United Group Inc
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD330121
Entity Address
4212 W 16 AV
Hialeah, FL 33012
Grant Number
NH25PS004342
Participating Start Date
1/1/2020
Last Recertification Date
5/22/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
EZ RX HALLANDALE LLC
Pharmacy Address
1550 W 84TH ST STE 62
HIALEAH, FL 33014-3379
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Augustine Carbon, President
(305) 788-0007
Contract Pharmacy Representative
Ez Rx Hallandale llc
Mirtha Gonzalez, pharmacy manager
(786) 703-5670
Signed By Date
4/12/2021
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