Provider Demographics
NPI:1689077000
Name:KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Other - Org Name:KAISER PERMANENTE KEIZER STATION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIRECTOR REGIONAL PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD, BCPS
Authorized Official - Phone:503-261-7980
Mailing Address - Street 1:5725 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3409
Mailing Address - Country:US
Mailing Address - Phone:844-854-9346
Mailing Address - Fax:503-304-5721
Practice Address - Street 1:5940 ULALI DR NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-1500
Practice Address - Country:US
Practice Address - Phone:844-854-9364
Practice Address - Fax:503-304-5721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP-00029843336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3845318OtherNCPDP
OR500678090Medicaid
2148106OtherPK