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BALAJI PHARMA LLC
STD336132 Doctors Goodwill Foundation, Inc.
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Covered Entity Details
Entity Name
Doctors Goodwill Foundation, Inc.
Subdivision Name
Emmanuel Mompi, MD
Type
Sexually Transmitted Diseases
340B ID
STD336132
Entity Address
3228 Cove Bend Dr.
#223
Tampa, FL 33613
Grant Number
NH25PS005131
Participating Start Date
10/1/2024
Last Recertification Date
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
8/12/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kantilal Bhalani, CEO
(321) 298-5531 Ext: 9414416212
Contract Pharmacy Representative
Palm Plaza Pharmacy.
Dipesh Patel, Owner
(813) 689-7700
Signed By Date
7/9/2024
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