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WALMART PHARMACY 10-5169
STD890522 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Galleria Women's Health
Type
Sexually Transmitted Diseases
340B ID
STD890522
Entity Address
2225 Village Walk Dr
Suite 270
Henderson, NV 89052
Grant Number
6 NH25PS005179-03-05
Participating Start Date
5/1/2023
Last Recertification Date
5/18/2023
Entity Termination Date
1/1/2024
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
1/1/2024
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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