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ALBERTSON'S LLC
STD89148 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Fort Apache SACI
Type
Sexually Transmitted Diseases
340B ID
STD89148
Entity Address
5731 S Fort Apache Rd
Suite 130
Las Vegas, NV 89148
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
ALBERTSON'S LLC
Pharmacy Address
SAV-ON PHARMACY #0460
11720 W. CHARLESTON BLVD.
LAS VEGAS, NV 89135
Pharmacy Comments
Contract Details
Approval Date
5/1/2023
Contract Begin Date
6/15/2023
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
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
4/25/2023
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