Covered Entity Details

STD93129 Source LGBT Center, INC (Active) - information as of 6/14/2025 10:07:44 AM

Main Details

Name

Source LGBT Center, INC

Subdivision Name

The Source LGBT+ Center

Type

Sexually Transmitted Diseases

340B ID

STD93129

Grant Number

1H25PS005127

Nature of Support
Please Describe the “in-kind” Support
Time period section 318 funding or in-kind support was received

In-Kind products or services (see note below; must have been purchased with section 318 funds)
Note: In-kind contributions may be in the form of real property, equipment, supplies and other expendable property, and goods and services directly benefiting and specifically identifiable to the project or program.
Condoms; other types of in-kind support received
1/1/2019 - 1/31/2026

Additional Details

Current Program Status

Active

Registration Date

1/11/2024

Participating Start Date

4/1/2024

Participating Approval Date

2/2/2024

Last Recertification Date

5/5/2025

Notice of Funding Opportunity (NOFO) Number

PS19-1901

Contacts

Authorizing Official

The Source LGBT+ Center
Brian Poth, Executive Director
(559) 429-4277 Ext: 8

Primary Contact

The Source LGBT+ Center
Dean Jackson, Program Director, HIV Services
(559) 429-4277 Ext: 6

Addresses

Street Address

109 NW 2nd Avenue
Visalia, CA 93291

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	ICARE RX LLC	14447 COUNTRY WALK DR		MIAMI	FL	33186	02/02/2024	04/01/2024	04/01/2024
Contract Detail	PHYSICIAN'S RX PHARMACY, LLC	PHYSICIANS RX PHARMACY, LLC	9701 APOLLO DRIVE #400	LARGO	MD	20774	02/02/2024	04/01/2024	04/01/2024
Contract Detail	PRXP OF CA LLC	PRXP OF CA LLC	4345 E LOWELL ST STE C & D	ONTARIO	CA	91761	02/02/2024	04/01/2024	04/01/2024
Contract Detail	PRXP OF NEW YORK LLC	DBA BROADWAY FAMILY PHARMACY	601 AMSTERDAM AVE	NEW YORK	NY	10024	02/02/2024	04/01/2024	04/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	5/6/2024 11:59:34 AM	5/5/2025 7:51:15 PM	5/5/2025 7:51 PM
Details	Nature of Support: Support Received From Date	Update	Change Request	10/10/2023 12:00:00 AM	1/1/2019 12:00:00 AM	6/5/2024 4:55 PM
Details	Nature of Support: Support Received To Date	Update	Change Request		1/31/2026 12:00:00 AM	6/5/2024 4:55 PM
Details	Last Recertification Date	Update	Recertification		5/6/2024 11:59:34 AM	5/6/2024 11:59 AM
Details	Entity Name	Update	Change Request	The Source LGBT+ Center	Source LGBT Center, INC	4/1/2024 6:08 AM
Details	Entity Subname	Update	Change Request		The Source LGBT+ Center	4/1/2024 6:08 AM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Addresses	Main Address	Update	Change Request	109 NW 2nd Avenue Visalia, CA 93129	109 NW 2nd Avenue Visalia, CA 93291	3/7/2024 12:57 PM
Contacts	Signed By	Insert	New Registration		Poth, Brian Executive Director The Source LGBT+ Center 5594294277-8	2/2/2024 3:44 PM
Details	340B ID	Update	New Registration		STD93129	2/2/2024 3:44 PM
Dates	Participating Approval Date	Update	New Registration		2/2/2024 3:44:43 PM	2/2/2024 3:44 PM
Details	State	Update	New Registration	Pending	Approved	2/2/2024 3:44 PM
Dates	Signed By Date	Update	New Registration		1/11/2024 6:17:07 PM	2/2/2024 3:44 PM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	2/2/2024 3:44 PM
Addresses	Main Address	Insert	New Registration		109 NW 2nd Avenue Visalia, CA 93129	1/11/2024 12:35 PM
Details	Nature of Support: In Kind Support Description	Insert	New Registration		Condoms; other types of in-kind support received	1/11/2024 12:35 PM
Details	Nature Of Support	Insert	New Registration		In-Kind products or services (see note below; must have been purchased with section 318 funds)	1/11/2024 12:35 PM
Details	Nature of Support: Support Received From Date	Insert	New Registration		10/10/2023 12:00:00 AM	1/11/2024 12:35 PM
Details	Nature of Support: Support Received To Date	Insert	New Registration			1/11/2024 12:35 PM
Contacts	Primary Contact	Insert	New Registration		Jackson, Dean Program Director, HIV Services The Source LGBT+ Center 5594294277-6	1/11/2024 12:35 PM
Contacts	Authorizing Official	Insert	New Registration		Poth, Brian Executive Director The Source LGBT+ Center 5594294277-8	1/11/2024 12:35 PM
Details	Assistance Received From Date	Insert	New Registration			1/11/2024 12:35 PM
Details	Assistance Received To Date	Insert	New Registration			1/11/2024 12:35 PM
Details	Last Recertification Date	Insert	New Registration			1/11/2024 12:35 PM
Details	Grant Number	Insert	New Registration		1H25PS005127	1/11/2024 12:35 PM
Details	340B ID	Insert	New Registration			1/11/2024 12:35 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/11/2024 12:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/11/2024 12:35 PM
Details	Medicare Provider Number	Insert	New Registration			1/11/2024 12:35 PM
Details	Entity Name	Insert	New Registration		The Source LGBT+ Center	1/11/2024 12:35 PM
Details	NOFO Number	Insert	New Registration		PS19-1901	1/11/2024 12:35 PM
Details	Program Code	Insert	New Registration		STD	1/11/2024 12:35 PM
Details	Entity Subname	Insert	New Registration			1/11/2024 12:35 PM
Dates	Participating Approval Date	Insert	New Registration			1/11/2024 12:35 PM
Details	State	Insert	New Registration		Pending	1/11/2024 12:35 PM
Dates	Registration Date	Insert	New Registration		1/11/2024 12:35:56 PM	1/11/2024 12:35 PM
Dates	Signed By Date	Insert	New Registration			1/11/2024 12:35 PM
Dates	Start Date	Insert	New Registration			1/11/2024 12:35 PM
Terminations	Termination Comments	Insert	New Registration			1/11/2024 12:35 PM
Terminations	Termination Date	Insert	New Registration			1/11/2024 12:35 PM
Terminations	Termination Effective Date	Insert	New Registration			1/11/2024 12:35 PM
Terminations	Termination Reason	Insert	New Registration			1/11/2024 12:35 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History