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FACTOR ONE SOURCE PHARMACY LLC
STD891287 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Nevada Home Infusions
Type
Sexually Transmitted Diseases
340B ID
STD891287
Entity Address
2435 Fire Mesa Street
Suite 130
Las Vegas, NV 89128
Grant Number
6 NH25PS005179-05-03
Participating Start Date
5/8/2023
Last Recertification Date
6/11/2024
Entity Termination Date
1/14/2025
Pharmacy Details
Pharmacy Name
FACTOR ONE SOURCE PHARMACY LLC
Pharmacy Address
DBA INFUCARE RX OF MD
217 GLENN ST STE 300
CUMBERLAND, MD 21502-2590
Pharmacy Comments
Contract Details
Approval Date
5/5/2023
Contract Begin Date
6/13/2023
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
Infucare
Mark Milburn, 340B Director
(877) 828-3940
Signed By Date
5/5/2023
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