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SAFEWAY INC
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
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1210
5150 MAE ANNE AVE #300
RENO, NV 89523
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
4/1/2024
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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