Provider Demographics
NPI:1083900831
Name:KAISER FOUNDATION HEALTHPLAN OF COLORADO
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTHPLAN OF COLORADO
Other - Org Name:KAISER PERMANENTE CASTLE ROCK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENESE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-326-6717
Mailing Address - Street 1:4318 TRAIL BOSS DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7512
Mailing Address - Country:US
Mailing Address - Phone:303-814-4170
Mailing Address - Fax:303-814-4170
Practice Address - Street 1:4318 TRAIL BOSS DR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7512
Practice Address - Country:US
Practice Address - Phone:303-814-4160
Practice Address - Fax:303-814-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8273336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130720OtherPK