Provider Demographics
NPI:1588860951
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE PHARMACY #572
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY OPERATIONS & 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:925-826-2542
Mailing Address - Fax:510-625-3307
Practice Address - Street 1:4501 SAND CREEK RD
Practice Address - Street 2:1ST FLR RM 1125
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8687
Practice Address - Country:US
Practice Address - Phone:925-813-7940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY485813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA485810Medicaid
5627293OtherNCPDP PROVIDER IDENTIFICATION NUMBER