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OPTUM PHARMACY 702, LLC
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
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/16/2023
Contract Begin Date
6/14/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
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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