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WAL-MART PHARMACY 10-1584
STD891441 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
New Eyes - Summerlin Clinic
Type
Sexually Transmitted Diseases
340B ID
STD891441
Entity Address
10105 Banburry Cross Dr.
Suite 255
Las Vegas, NV 89144
Grant Number
6 NH25PS005179-03-05
Participating Start Date
5/1/2023
Last Recertification Date
5/18/2023
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1584
Pharmacy Address
3615 SOUTH RAINBOW ROAD
LAS VEGAS, NV 89103
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
10/1/2023
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
4/24/2023
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