Provider Demographics
NPI:1497183271
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE PHARMACY #105
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY OPERATIONS AND SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:RENOUARD
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-625-2363
Mailing Address - Street 1:1800 HARRISON ST FL 13
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3466
Mailing Address - Country:US
Mailing Address - Phone:510-752-4200
Mailing Address - Fax:
Practice Address - Street 1:3600 BROADWAY FL 1
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611
Practice Address - Country:US
Practice Address - Phone:510-752-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY516363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142505OtherPK
CA1497183271Medicaid
5649085OtherNCPDP