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GOODWILL PHARMACY INC.
STD89012 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Dr. S. Steven Kim, MD - MDVIP
Type
Sexually Transmitted Diseases
340B ID
STD89012
Entity Address
1720 W Horizon Ridge Pkwy
#140
Henderson, NV 89012
Grant Number
6 NH25PS005179-05-02
Participating Start Date
5/1/2023
Last Recertification Date
5/22/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
GOODWILL PHARMACY INC.
Pharmacy Address
2610 S JONES BLVD STE 3
LAS VEGAS, NV 89146-5663
Pharmacy Comments
Contract Details
Approval Date
10/25/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jami Dybik, Vice President
(843) 814-5177
Contract Pharmacy Representative
Goodwill Pharmacy Inc.
Arun Pasricha, Owner
(702) 213-3102
Signed By Date
10/25/2023
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