1972650208 NPI number — KAISER FOUNDATION HEALTH PLAN INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972650208 NPI number — KAISER FOUNDATION HEALTH PLAN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER FOUNDATION HEALTH PLAN INC
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 PHARMACY #868
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:
1972650208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12254 BELLFLOWER BLVD FL2
Provider Second Line Business Mailing Address:
PHARMACY OPERATIONS
Provider Business Mailing Address City Name:
DOWNEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90242-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 036 GERALD FORD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-279-8954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POLCHAK
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
VP PHARMACY OPERATIONS & SVCS, SCAL
Authorized Official Telephone Number:
562-658-3510

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY47564 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1972650208 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5622510 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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