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PROXYCARE
STD891284 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Fire Mesa Rheumatology
Type
Sexually Transmitted Diseases
340B ID
STD891284
Entity Address
2435 Fire Mesa Street
Suite 110
Las Vegas, NV 89128
Grant Number
6 NH25PS005179-05-03
Participating Start Date
5/1/2023
Last Recertification Date
6/1/2024
Entity Termination Date
1/14/2025
Pharmacy Details
Pharmacy Name
PROXYCARE
Pharmacy Address
747 SHOTGUN RD
SUNRISE, FL 33326
Pharmacy Comments
Contract Details
Approval Date
4/30/2024
Contract Begin Date
7/1/2024
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
Proxycare Inc.
Cindy Cruz, President
(954) 791-5400
Signed By Date
4/30/2024
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