Provider Demographics
NPI:1689721904
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER HEALTH PLAN MODESTO PHY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OP PHARMACY MGR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-557-1146
Mailing Address - Street 1:1625 I ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 I ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1121
Practice Address - Country:US
Practice Address - Phone:209-557-1115
Practice Address - Fax:209-557-1125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY415993336C0002X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA415990Medicaid
0543682OtherOTHER ID NUMBER-COMMERCIAL NUMBER