Provider Demographics
NPI:1518326651
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE PHARMACY #622
Other - Org Type:Other Name
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 1:2025 MORSE AVE
Mailing Address - Street 2:FL 3, RM 3860 & 3861
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:FL 3, RM 3860 & 3861
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2115
Practice Address - Country:US
Practice Address - Phone:916-973-5945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY54162333600000X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy