Provider Demographics
NPI:1093142234
Name:KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Other - Org Name:KAISER PERMANENTE GATEWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC. DIRECTOR, PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-261-7566
Mailing Address - Street 1:5725 NE 138TH AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3409
Mailing Address - Country:US
Mailing Address - Phone:503-261-2166
Mailing Address - Fax:503-261-2166
Practice Address - Street 1:1700 NE 102ND AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:866-279-4581
Practice Address - Fax:971-229-6861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0002839-CS3336C0002X
3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRP-0002839-CSOtherBOP LICENSE
OR500664821Medicaid