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PRXP OF NEW YORK LLC
STD93129 Source LGBT Center, INC
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Covered Entity Details
Entity Name
Source LGBT Center, INC
Subdivision Name
The Source LGBT+ Center
Type
Sexually Transmitted Diseases
340B ID
STD93129
Entity Address
109 NW 2nd Avenue
Visalia, CA 93291
Grant Number
1H25PS005127
Participating Start Date
4/1/2024
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
PRXP OF NEW YORK LLC
Pharmacy Address
DBA BROADWAY FAMILY PHARMACY
601 AMSTERDAM AVE
NEW YORK, NY 10024
Pharmacy Comments
Contract Details
Approval Date
2/2/2024
Contract Begin Date
4/1/2024
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
1/11/2024
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