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AVITA PHARMACY 1018
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
AVITA PHARMACY 1018
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
2740 S ELM AVE RM 2
FRESNO, CA 93706-5435
Pharmacy Comments
Contract Details
Approval Date
7/14/2022
Contract Begin Date
7/19/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2024
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
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/14/2022
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