1124462940 NPI number — KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST

Table of content: (NPI 1124462940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124462940 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 WESTSIDE MEDICAL CENTER 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:
1124462940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
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:
866-280-0511
Provider Business Mailing Address Fax Number:
971-310-3351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2875 NW STUCKI AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97124-5806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-280-0511
Provider Business Practice Location Address Fax Number:
971-310-3351
Provider Enumeration Date:
04/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LYMAN
Authorized Official First Name:
ALFRED
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
EXEC. DIRECTOR PHARMACY SERVICES
Authorized Official Telephone Number:
503-261-7980

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  0002241 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0003X , with the licence number: 0002771 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3844708 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: RP-0002771-CS . This is a "BOP LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 2038157 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50065832 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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