Provider Demographics
NPI:1932114535
Name:VIA LIDO DRUG CORPORATION
Entity Type:Organization
Organization Name:VIA LIDO DRUG CORPORATION
Other - Org Name:VIA LIDO DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-715-9041
Mailing Address - Street 1:18 TECHNOLOGY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-5303
Mailing Address - Country:US
Mailing Address - Phone:949-715-9041
Mailing Address - Fax:949-723-8929
Practice Address - Street 1:3445 VIA LIDO
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3908
Practice Address - Country:US
Practice Address - Phone:949-723-8921
Practice Address - Fax:949-723-8929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA561893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA40860Medicaid
1995453OtherPK