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AVITA PHARMACY 1025
STD891012 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Bonanza Clinic
Type
Sexually Transmitted Diseases
340B ID
STD891012
Entity Address
2345 East Bonanza Road
Las Vegas, NV 89101
Grant Number
6 NH25PS005179-03-05
Participating Start Date
1/1/2022
Last Recertification Date
6/6/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1025
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
3020 SATURN ST STE 100
BREA, CA 92821
Pharmacy Comments
Contract Details
Approval Date
7/8/2022
Contract Begin Date
8/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Vladimir Abadjiev, Operations Manager
(702) 526-3146
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/8/2022
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