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LIFECARE PHARMACY, LLC
STD891483 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
LifeCare Clinic
Type
Sexually Transmitted Diseases
340B ID
STD891483
Entity Address
6415 S Fort Apache Rd
Ste 175
Las Vegas, NV 89148
Grant Number
6 NH25PS005179-05-03
Participating Start Date
5/8/2023
Last Recertification Date
6/4/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
LIFECARE PHARMACY, LLC
Pharmacy Address
DBA: LIFECARE PHARMACY
3050 E. DESERT INN RD.
STE#124
LAS VEGAS, NV 89121-3873
Pharmacy Comments
Contract Details
Approval Date
5/5/2023
Contract Begin Date
5/11/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jami Dybik, Vice President
(843) 814-5177
Contract Pharmacy Representative
LifeCare Specialty Pharmacy
CLETUS AMADI, Owner
(702) 697-2105
Signed By Date
5/4/2023
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