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LONGS DRUGS OF LEXINGTON
STD891283 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Northwest Clinic - NKDHC
Type
Sexually Transmitted Diseases
340B ID
STD891283
Entity Address
2450 Fire Mesa St
Ste 110
Las Vegas, NV 89128
Grant Number
6 NH25PS005179-05-02
Participating Start Date
11/29/2022
Last Recertification Date
5/31/2023
Entity Termination Date
4/1/2024
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
4/1/2024
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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