Contract Pharmacy Details

PROXYCARE
STD891061 Sagebrush Health Services

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

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