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LONGS DRUGS OF LEXINGTON
STD89005 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Boulder City Clinic
Type
Sexually Transmitted Diseases
340B ID
STD89005
Entity Address
1252 Wyoming St
Boulder City, NV 89005
Grant Number
6 NH25PS005179-03-05
Participating Start Date
11/29/2022
Last Recertification Date
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
LONGS DRUGS OF LEXINGTON
Pharmacy Address
D/B/A AVITA PHARMACY 1051
1216 W MAIN ST
STE D
LEXINGTON, SC 29072-2453
Pharmacy Comments
Contract Details
Approval Date
11/29/2022
Contract Begin Date
12/15/2022
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
10/17/2022
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