Covered Entity Details

RWII93291 Source LGBT Center, INC (Active) - information as of 5/5/2025 12:08:21 AM

Main Details

Name

Source LGBT Center, INC

Subdivision Name

The Source LGBT+ Center

Type

Ryan White Part B

340B ID

RWII93291

Grant Number

X07HA12778

Additional Details

Current Program Status

Active

Registration Date

1/23/2022

Participating Start Date

4/1/2022

Participating Approval Date

1/28/2022

Last Recertification Date

2/10/2025

Time Period the Assistance was Received

7/1/2020 - 6/30/2029

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

The Source LGBT+ Center
PO Box 188
Visalia, CA 93279

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
Participating from effective date: (1/1/2021) until terminated effective date: (1/1/2022), reinstatement effective date: (4/1/2022)	01/28/2022

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	Termination Date	Last Updated On
Contract Detail	AVITA PHARMACY 1018	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2740 S ELM AVE RM 2	FRESNO	CA	93706-5435	07/14/2022	07/19/2022	07/15/2024	07/15/2024
Contract Detail	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	07/14/2022	07/19/2022	07/15/2024	07/15/2024
Contract Detail	AVITA PHARMACY 1040	AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10	6100 CORPORATE BLVD STE 250	BATON ROUGE	LA	70808	07/14/2022	07/19/2022	07/15/2024	07/15/2024
Contract Detail	CHERRY PHARMACY CUTLER INC	40657 ROAD 128		CUTLER	CA	93615	07/08/2021	10/01/2021	12/14/2021	12/15/2021
Contract Detail	CHERRY PHARMACY CUTLER INC	40657 ROAD 128		CUTLER	CA	93615	01/28/2022	04/01/2022	02/17/2022	02/17/2022
Contract Detail	CHERRY STREET PHARMACY	ACE CARE PHARMACY MANAGEMENT & CONSULTIN	1053 N CHERRY ST	TULARE	CA	93274	07/08/2021	10/01/2021	12/14/2021	12/15/2021
Contract Detail	CHERRY STREET PHARMACY	ACE CARE PHARMACY MANAGEMENT & CONSULTIN	1053 N CHERRY ST	TULARE	CA	93274	01/28/2022	04/01/2022	02/17/2022	02/17/2022
Contract Detail	GARDEN GROVE COMMUNITY PHARMACY	12665 GARDEN GROVE BLVD STE 108		GARDEN GROVE	CA	92843-1915	04/15/2021	07/01/2021	12/14/2021	12/15/2021
Contract Detail	GARDEN GROVE COMMUNITY PHARMACY	12665 GARDEN GROVE BLVD STE 108		GARDEN GROVE	CA	92843-1915	01/28/2022	04/01/2022	02/17/2022	02/17/2022
Contract Detail	ICARE RX LLC	14447 COUNTRY WALK DR		MIAMI	FL	33186	11/30/2020	01/01/2021	01/01/2022	01/01/2022
Contract Detail	ICARE RX LLC	14447 COUNTRY WALK DR		MIAMI	FL	33186	07/14/2022	07/19/2022		07/19/2022
Contract Detail	LONGS DRUGS OF LEXINGTON	D/B/A AVITA PHARMACY 1051	1216 W MAIN ST STE D	LEXINGTON	SC	29072-2453	07/14/2022	07/19/2022	07/15/2024	07/15/2024
Contract Detail	PHYSICIAN'S RX PHARMACY, LLC	PHYSICIANS RX PHARMACY, LLC	9701 APOLLO DRIVE #400	LARGO	MD	20774	11/30/2020	01/01/2021	01/01/2022	01/01/2022
Contract Detail	PHYSICIAN'S RX PHARMACY, LLC	PHYSICIANS RX PHARMACY, LLC	9701 APOLLO DRIVE #400	LARGO	MD	20774	07/14/2022	07/19/2022		07/19/2022
Contract Detail	PRXP OF CA LLC	PRXP OF CA LLC	4345 E LOWELL ST STE C & D	ONTARIO	CA	91761	11/30/2020	01/01/2021	01/01/2022	01/01/2022
Contract Detail	PRXP OF CA LLC	PRXP OF CA LLC	4345 E LOWELL ST STE C & D	ONTARIO	CA	91761	07/14/2022	07/19/2022		07/19/2022
Contract Detail	PRXP OF NEW YORK LLC	DBA BROADWAY FAMILY PHARMACY	601 AMSTERDAM AVE	NEW YORK	NY	10024	11/30/2020	01/01/2021	01/01/2022	01/01/2022
Contract Detail	PRXP OF NEW YORK LLC	DBA BROADWAY FAMILY PHARMACY	601 AMSTERDAM AVE	NEW YORK	NY	10024	07/14/2022	07/19/2022		07/19/2022

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/31/2024 11:03:26 AM	2/10/2025 12:22:08 PM	2/10/2025 12:22 PM
Details	Assistance Received From Date	Update	Change Request	4/1/2021 12:00:00 AM	7/1/2020 12:00:00 AM	4/2/2024 2:28 PM
Details	Assistance Received To Date	Update	Change Request	3/31/2024 12:00:00 AM	6/30/2029 12:00:00 AM	4/2/2024 2:28 PM
Details	Last Recertification Date	Update	Recertification	1/30/2023 4:33:07 PM	1/31/2024 11:03:26 AM	1/31/2024 11:03 AM
Details	NOFO Number	Update		HRSA-17-036		12/16/2023 10:34 AM
Details	Last Recertification Date	Update	Recertification		1/30/2023 4:33:07 PM	1/30/2023 4:33 PM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Addresses	Main Address	Insert	Reinstatement		109 NW 2nd Avenue Visalia, CA 93291	1/28/2022 8:01 AM
Addresses	Billing Address	Insert	Reinstatement		The Source LGBT+ Center PO Box 188 Visalia, CA 93279	1/28/2022 8:01 AM
Details	Last Recertification Date	Update	Reinstatement	2/5/2021 1:14:57 PM		1/28/2022 8:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	12/17/2021 12:00:00 AM		1/28/2022 8:01 AM
Dates	Participating Approval Date	Update	Reinstatement	11/30/2020 1:15:37 PM	1/28/2022 8:01:10 AM	1/28/2022 8:01 AM
Details	State	Update	Reinstatement	Terminated	Approved	1/28/2022 8:01 AM
Dates	Registration Date	Update	Reinstatement	10/1/2020 2:43:22 PM	1/23/2022 6:09:32 PM	1/28/2022 8:01 AM
Dates	Signed By Date	Update	Reinstatement	10/9/2020 4:45:15 PM	1/23/2022 9:27:30 PM	1/28/2022 8:01 AM
Dates	Start Date	Update	Reinstatement	1/1/2021 12:00:00 AM	4/1/2022 12:00:00 AM	1/28/2022 8:01 AM
Terminations	Termination Date	Update	Reinstatement	1/1/2022 12:00:00 AM		1/28/2022 8:01 AM
Terminations	Termination Effective Date	Update	Reinstatement	12/31/2021 12:00:00 AM		1/28/2022 8:01 AM
Terminations	Termination Reason	Update	Reinstatement	Business decision by the Covered Entity		1/28/2022 8:01 AM
Details	Comments Public	Insert	Reinstatement		Participating from effective date: (1/1/2021) until terminated effective date: (1/1/2022), reinstatement effective date: (4/1/2022)	1/28/2022 6:23 AM
Contacts	Primary Contact	Update	Reinstatement	Jackson, Dean Program Director, HIV Services The Source LGBT+ Center 5594294277-3	Jackson, Dean Program Director, HIV Services The Source LGBT+ Center 5594294277-6	1/23/2022 6:09 PM
Contacts	Authorizing Official	Update		Poth, Brian Executive Director The Source LGBT+ Center 5594294277-1	Poth, Brian Executive Director The Source LGBT+ Center 5594294277-8	1/18/2022 12:44 PM
Contacts	Signed By	Update		Poth, Brian Executive Director The Source LGBT+ Center 5594294277-1	Poth, Brian Executive Director The Source LGBT+ Center 5594294277-8	1/18/2022 12:44 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/17/2021 12:00:00 AM	12/22/2021 7:55 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/22/2021 7:55 AM
Terminations	Termination Date	Update	Termination Request		1/1/2022 12:00:00 AM	12/22/2021 7:55 AM
Terminations	Termination Effective Date	Update	Termination Request		12/31/2021 12:00:00 AM	12/22/2021 7:55 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	12/22/2021 7:55 AM
Addresses	Main Address	Update	Change Request	208 W. Main Street Suite B Visalia, CA 93291	109 NW 2nd Avenue Visalia, CA 93291	10/6/2021 2:57 PM
Details	Assistance Received From Date	Update	Change Request	4/1/2016 12:00:00 AM	4/1/2021 12:00:00 AM	4/1/2021 8:34 PM
Details	Assistance Received To Date	Update	Change Request	3/31/2021 12:00:00 AM	3/31/2024 12:00:00 AM	4/1/2021 8:34 PM
Details	Last Recertification Date	Update	Recertification		2/5/2021 1:14:57 PM	2/5/2021 1:14 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Addresses	Main Address	Insert	New Registration		208 W. Main Street Suite B Visalia, CA 93291	11/30/2020 1:15 PM
Contacts	Signed By	Insert	New Registration		Poth, Brian Executive Director The Source LGBT+ Center 5594294277-1	11/30/2020 1:15 PM
Details	Assistance Received From Date	Update	New Registration	7/1/2020 12:00:00 AM	4/1/2016 12:00:00 AM	11/30/2020 1:15 PM
Details	Grant Number	Update	New Registration	PA7017	X07HA12778	11/30/2020 1:15 PM
Details	340B ID	Update	New Registration		RWII93291	11/30/2020 1:15 PM
Details	NOFO Number	Update	New Registration	HRSA-21-067	HRSA-17-036	11/30/2020 1:15 PM
Dates	Participating Approval Date	Update	New Registration		11/30/2020 1:15:37 PM	11/30/2020 1:15 PM
Details	State	Update	New Registration	Pending	Approved	11/30/2020 1:15 PM
Dates	Signed By Date	Update	New Registration		10/9/2020 4:45:15 PM	11/30/2020 1:15 PM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	11/30/2020 1:15 PM
Addresses	Main Address	Insert	New Registration		208 W. Main Street Suite B Visalia, CA 93291	10/1/2020 2:43 PM
Contacts	Primary Contact	Insert	New Registration		Jackson, Dean Program Director, HIV Services The Source LGBT+ Center 5594294277-3	10/1/2020 2:43 PM
Contacts	Authorizing Official	Insert	New Registration		Poth, Brian Executive Director The Source LGBT+ Center 5594294277-1	10/1/2020 2:43 PM
Details	Assistance Received From Date	Insert	New Registration		7/1/2020 12:00:00 AM	10/1/2020 2:43 PM
Details	Assistance Received To Date	Insert	New Registration		3/31/2021 12:00:00 AM	10/1/2020 2:43 PM
Details	Last Recertification Date	Insert	New Registration			10/1/2020 2:43 PM
Details	Grant Number	Insert	New Registration		PA7017	10/1/2020 2:43 PM
Details	340B ID	Insert	New Registration			10/1/2020 2:43 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/1/2020 2:43 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/1/2020 2:43 PM
Details	Medicare Provider Number	Insert	New Registration			10/1/2020 2:43 PM
Details	Entity Name	Insert	New Registration		Source LGBT Center, INC	10/1/2020 2:43 PM
Details	NOFO Number	Insert	New Registration		HRSA-21-067	10/1/2020 2:43 PM
Details	Program Code	Insert	New Registration		RWII	10/1/2020 2:43 PM
Details	Entity Subname	Insert	New Registration		The Source LGBT+ Center	10/1/2020 2:43 PM
Dates	Participating Approval Date	Insert	New Registration			10/1/2020 2:43 PM
Details	State	Insert	New Registration		Pending	10/1/2020 2:43 PM
Dates	Registration Date	Insert	New Registration		10/1/2020 2:43:22 PM	10/1/2020 2:43 PM
Dates	Signed By Date	Insert	New Registration			10/1/2020 2:43 PM
Dates	Start Date	Insert	New Registration			10/1/2020 2:43 PM
Terminations	Termination Comments	Insert	New Registration			10/1/2020 2:43 PM
Terminations	Termination Date	Insert	New Registration			10/1/2020 2:43 PM
Terminations	Termination Effective Date	Insert	New Registration			10/1/2020 2:43 PM
Terminations	Termination Reason	Insert	New Registration			10/1/2020 2:43 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History