Provider Demographics
NPI:1255488573
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER HEALTH PLAN DIVISADERO PHY 314
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP NAT'L PHRMCY PROG & SVCS
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KVANCZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-658-3510
Mailing Address - Street 1:12254 BELLFLOWER BLVD FL 2
Mailing Address - Street 2:PHARMACY PROFESSIONAL AFFAIRS
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2804
Mailing Address - Country:US
Mailing Address - Phone:562-658-3671
Mailing Address - Fax:
Practice Address - Street 1:1635 DIVISADERO ST FL 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3036
Practice Address - Country:US
Practice Address - Phone:415-833-4507
Practice Address - Fax:415-833-3719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
CAPHY358323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA358320Medicaid
0508993OtherNCPDP PROVIDER IDENTIFICATION NUMBER