1063604676 NPI number — KAISER FOUNDATION HEALTH PLAN INC

Table of content: (NPI 1063604676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063604676 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:
Provider Other Organization Name Type Code:
6
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:
1063604676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2024
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
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:
2200 E GONZALES RD
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93036-0619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-407-7720
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2007

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: PHY48571 , 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: 5626912 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1063604676 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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