1922281906 NPI number — KAISER FOUNDATION HEALTH PLAN INC

Table of content: (NPI 1922281906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922281906 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 PHY #193
Provider Other Organization Name Type Code:
5
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:
1922281906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12254 BELLFLOWER BLVD FL 2
Provider Second Line Business Mailing Address:
PHARMACY OPERATIONS DEPARTMENT
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:
17296 SLOVER AVE
Provider Second Line Business Practice Location Address:
PALM COURT 1
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92337-7585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-609-3360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2007

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: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PHY48828 , 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: 5628827 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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