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OPTUM PHARMACY 702, LLC
STD891286 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Dr. Ann Wierman, MD
Type
Sexually Transmitted Diseases
340B ID
STD891286
Entity Address
3150 N. Tenaya Way
Ste 200
Las Vegas, NV 89128
Grant Number
6 NH25PS005179-05-03
Participating Start Date
5/1/2023
Last Recertification Date
6/1/2024
Entity Termination Date
1/14/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/1/2023
Contract Begin Date
6/14/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jami Dybik, Vice President
(843) 814-5177
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/16/2023
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