1790113371 NPI number — KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST

Table of content: (NPI 1790113371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790113371 NPI number — KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KAISER PERMANENTE LONGVIEW KELSO ONCOLOGY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790113371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5725 NE 138TH AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97230-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-261-2166
Provider Business Mailing Address Fax Number:
503-261-2166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 7TH AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-279-8943
Provider Business Practice Location Address Fax Number:
360-636-6271
Provider Enumeration Date:
10/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LOGAN
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC. DIRECTOR PHARMACY SERVICES
Authorized Official Telephone Number:
503-261-7566

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  PHAR.CF.60362983 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6019384 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PHAR.CF.60362983WA . This is a "BOP LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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