Provider Demographics
NPI:1730108168
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 INTERSTATE SOUTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, REGIONAL PHARMA
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, BCPS
Authorized Official - Phone:800-813-2000
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:503-261-7980
Mailing Address - Fax:503-261-7567
Practice Address - Street 1:3500 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-331-6186
Practice Address - Fax:503-331-6187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHNR.FO.60572833333600000X
ORRP-0001643-CS3336C0002X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500622283Medicaid
WA6029821Medicaid
2078923OtherPK