Provider Demographics
NPI:1366836041
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 SKYLINE INSTITUTIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC. DIRECTOR PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD, BCPS
Authorized Official - Phone:503-261-7980
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:503-315-4650
Mailing Address - Fax:503-315-4682
Practice Address - Street 1:5125 SKYLINE RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9427
Practice Address - Country:US
Practice Address - Phone:503-315-4650
Practice Address - Fax:503-315-4682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRP0003050CSOtherSTATE LICENSE
OR500687040Medicaid
OR3845522OtherNCPDP
OR3845522OtherNCPDP