Provider Demographics
NPI:1689175192
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE PHARMACY #889
Other - Org Type:Other Name
Authorized Official - Title/Position:VP PHARMACY OPERATIONS & SVCS, SCAL
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:POLCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-658-3510
Mailing Address - Street 1:12254 BELLFLOWER BLVD FL 2
Mailing Address - Street 2:PHARMACY OPERATIONS
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4949 MARKET ST, 1ST FL
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:855-352-7974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY56087333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689175192Medicaid
CA5666017OtherNCPDP