Provider Demographics
NPI:1114467883
Name:KAISER PERMANENTE PHARMACY
Entity Type:Organization
Organization Name:KAISER PERMANENTE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:909-367-7080
Mailing Address - Street 1:1183 E FOOTHILL BLVD
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4079
Mailing Address - Country:US
Mailing Address - Phone:909-367-7080
Mailing Address - Fax:909-367-7076
Practice Address - Street 1:1183 E FOOTHILL BLVD
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4079
Practice Address - Country:US
Practice Address - Phone:909-367-7080
Practice Address - Fax:909-367-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36910302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization