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ICARE RX LLC
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
ICARE RX LLC
Pharmacy Address
14447 COUNTRY WALK DR
MIAMI, FL 33186
Pharmacy Comments
Contract Details
Approval Date
7/14/2022
Contract Begin Date
7/19/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Poth, Executive Director
(559) 429-4277 Ext: 8
Contract Pharmacy Representative
Physicians Rx Pharmacy of Clinton
Chris Wakefield, Manager
(412) 357-5163
Signed By Date
7/14/2022
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