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MY FAIR HAVEN PHARMACY LLC
STD064891 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Southington PrEP Clinic
Type
Sexually Transmitted Diseases
340B ID
STD064891
Entity Address
1131 West Street
Suite 3A
Southington, CT 06489
Grant Number
6 NU62PS924521-04-02
Participating Start Date
5/9/2023
Last Recertification Date
6/1/2024
Entity Termination Date
1/14/2025
Pharmacy Details
Pharmacy Name
MY FAIR HAVEN PHARMACY LLC
Pharmacy Address
D/B/A FAIR HAVEN PHARMACY
72 GRAND AVE
NEW HAVEN, CT 06513
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
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
My Fair Haven Pharmacy
Varma Manthena, Authorized Official
(203) 498-3479
Signed By Date
10/15/2024
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