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WALMART PHARMACY 10-5169
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
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
1/14/2025
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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