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FACTOR ONE SOURCE PHARMACY LLC
STD06489 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Southington Clinic - CT
Type
Sexually Transmitted Diseases
340B ID
STD06489
Entity Address
1131 West St. Building #1
Southington, CT 06489
Grant Number
6 NU62PS924521-04-02
Participating Start Date
12/28/2022
Last Recertification Date
6/4/2024
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
6/8/2023
Carve-In Effective Date
Contract Comments
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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