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DAWSON FAMILY PHARMACY
STD891281 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Fire Mesa ID
Type
Sexually Transmitted Diseases
340B ID
STD891281
Entity Address
2435 Fire Mesa Street
#120
Las Vegas, NV 89128
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
DAWSON FAMILY PHARMACY
Pharmacy Address
73 PRESTIGE LN STE 104
DAWSONVILLE, GA 30534-6368
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
dawsonfamilyrx@gmail.com
Surya Vangapandu, Pharmacist
(706) 203-1400
Signed By Date
1/28/2024
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