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BVA UNITED PHARMACY
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
BVA UNITED PHARMACY
Pharmacy Address
8845 SIX PINES DR STE 201
SHENANDOAH, TX 77380-2675
Pharmacy Comments
Contract Details
Approval Date
1/28/2024
Contract Begin Date
4/1/2024
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
BVA UNITED PHARMACY
Jolene Burton, PIC
(281) 465-1767
Signed By Date
1/28/2024
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