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FACTOR ONE SOURCE PHARMACY LLC
STD891281 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Fire Mesa ID
Type
Sexually Transmitted Diseases
340B ID
STD891281
Entity Address
2435 Fire Mesa Street
#120
Las Vegas, NV 89128
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
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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