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MY FAIR HAVEN PHARMACY LLC
STD068107 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Danbury Rd Clinic
Type
Sexually Transmitted Diseases
340B ID
STD068107
Entity Address
105 Newtown Rd
Ste B
Danbury, CT 06810
Grant Number
6 NU62PS924521-04-02
Participating Start Date
4/1/2023
Last Recertification Date
5/31/2024
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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