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WAL-MART PHARMACY 10-1559
STD89012 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Dr. S. Steven Kim, MD - MDVIP
Type
Sexually Transmitted Diseases
340B ID
STD89012
Entity Address
1720 W Horizon Ridge Pkwy
#140
Henderson, NV 89012
Grant Number
6 NH25PS005179-05-02
Participating Start Date
5/1/2023
Last Recertification Date
5/22/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1559
Pharmacy Address
201 NORTH NELLIS BLVD
LAS VEGAS (NE), NV 89110
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
4/1/2024
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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