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GARDEN GROVE COMMUNITY PHARMACY
RWII93291 Source LGBT Center, INC
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Covered Entity Details
Entity Name
Source LGBT Center, INC
Subdivision Name
The Source LGBT+ Center
Type
Ryan White Part B
340B ID
RWII93291
Entity Address
109 NW 2nd Avenue
Visalia, CA 93291
Grant Number
X07HA12778
Participating Start Date
4/1/2022
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
GARDEN GROVE COMMUNITY PHARMACY
Pharmacy Address
12665 GARDEN GROVE BLVD STE 108
GARDEN GROVE, CA 92843-1915
Pharmacy Comments
Contract Details
Approval Date
1/28/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/17/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brian Poth, Executive Director
(559) 429-4277 Ext: 8
Contract Pharmacy Representative
Garden Grove Community Pharmacy
Shekha Patel, Pharmacist
(714) 530-1130
Signed By Date
1/23/2022
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