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LIFECARE PHARMACY, LLC
STD891061 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Shadow Lane Neurology
Type
Sexually Transmitted Diseases
340B ID
STD891061
Entity Address
701 Shadow Lane
170
Las Vegas, NV 89106
Grant Number
6 NH25PS005179-05-03
Participating Start Date
1/1/2022
Last Recertification Date
6/11/2024
Entity Termination Date
1/14/2025
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
7/1/2023
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
LifeCare Specialty Pharmacy
CLETUS AMADI, Owner
(702) 697-2105
Signed By Date
5/5/2023
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