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VIA LIDO DRUGS
RWI92653 Shanti Orange County
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Covered Entity Details
Entity Name
Shanti Orange County
Subdivision Name
Type
Ryan White Part A
340B ID
RWI92653
Entity Address
23461 South Pointe Drive
Suite 100
Laguna Hills, CA 92653
Grant Number
H89HA00019
Participating Start Date
4/1/2017
Last Recertification Date
2/22/2025
Pharmacy Details
Pharmacy Name
VIA LIDO DRUGS
Pharmacy Address
3445 VIA LIDO
NEWPORT BEACH, CA 92663
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lindsay Ann Fitzpatrick, Executive Director
(949) 452-0888 Ext: 9494520888
Contract Pharmacy Representative
Laguna Drug
Dave Olsen, Owner
(949) 307-8335
Signed By Date
1/14/2019
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