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NEVADA CVS PHARMACY, L.L.C.
STD891485 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
ProCare Medical Group Fort Apache Clinic- Desert Mountain
Type
Sexually Transmitted Diseases
340B ID
STD891485
Entity Address
5270 S Fort Apache Rd.
Suite 330
Las Vegas, NV 89148
Grant Number
6 NH25PS005179-05-03
Participating Start Date
10/1/2023
Last Recertification Date
6/11/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
NEVADA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08809
4014 S. RAINBOW BLVD.
LAS VEGAS, NV 89103
Pharmacy Comments
Contract Details
Approval Date
9/4/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jami Dybik, Vice President
(843) 814-5177
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/26/2023
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