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AVITA PHARMACY 1040
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
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
4/8/2022
Contract Begin Date
4/13/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lindsay Ann Fitzpatrick, Executive Director
(949) 452-0888 Ext: 9494520888
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/8/2022
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