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WAL-MART PHARMACY 10-2592
STD890481 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Pahrump SACI
Type
Sexually Transmitted Diseases
340B ID
STD890481
Entity Address
1470 E Calvada Blvd
Suite 600
Pahrump, NV 89048
Grant Number
6 NH25PS005179-05-03
Participating Start Date
5/1/2023
Last Recertification Date
6/4/2024
Entity Termination Date
1/14/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2592
Pharmacy Address
1807 WEST CRAIG ROAD
NORTH LAS VEGAS, NV 89032
Pharmacy Comments
Contract Details
Approval Date
5/1/2023
Contract Begin Date
5/17/2023
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
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/16/2023
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