Provider Demographics
NPI:1528002474
Name:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN NORTHWEST
Other - Org Name:KAISER SUNNYSIDE OUTPATIENT PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNSCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-571-2022
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-571-4222
Mailing Address - Fax:503-571-4166
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-4222
Practice Address - Fax:503-571-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR006503336C0002X, 3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136742Medicaid
WA6019343Medicaid
OR3811848OtherNCPDP