Provider Demographics
NPI:1245567783
Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Other - Org Name:KAISER PERMANENTE SOUTHWOOD INFUSION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY COMPLIANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-712-5654
Mailing Address - Street 1:2400 MOUNT ZION PKWY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2500
Mailing Address - Country:US
Mailing Address - Phone:770-603-3847
Mailing Address - Fax:770-603-3561
Practice Address - Street 1:2400 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2500
Practice Address - Country:US
Practice Address - Phone:770-603-3847
Practice Address - Fax:770-603-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCL0000193336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122375OtherPK