Provider Demographics
NPI:1558419366
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER HOME HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:
Authorized Official - Last Name:ITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-427-4244
Mailing Address - Street 1:9961 SIERRA AVE
Mailing Address - Street 2:BUILDING 3B
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:BUILDING 3B
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-4244
Practice Address - Fax:909-427-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY412003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0565892OtherOTHER ID NUMBER
0565892OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHB365250Medicaid