Provider Demographics
NPI:1578885463
Name:KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC
Other - Org Name:KAISER PERMANENTE LARGO INFUSION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY BENEFITS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-466-4800
Mailing Address - Street 1:22370 DAVIS DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5367
Mailing Address - Country:US
Mailing Address - Phone:703-466-4800
Mailing Address - Fax:703-466-4802
Practice Address - Street 1:1221 MERCANTILE LN
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5374
Practice Address - Country:US
Practice Address - Phone:301-618-5880
Practice Address - Fax:301-618-5912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
MDPW03353336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123905OtherPK