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WALMART PHARMACY 10-5169
STD89113 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
New Eyes - Southwest Clinic
Type
Sexually Transmitted Diseases
340B ID
STD89113
Entity Address
8352 W. Warm Springs Rd
Suite 130
Las Vegas, NV 89113
Grant Number
6 NH25PS005179-03-05
Participating Start Date
5/1/2023
Last Recertification Date
5/18/2023
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
5/5/2023
Contract Begin Date
5/17/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jami Dybik, Vice President
(843) 814-5177
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
5/5/2023
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