Provider Demographics
NPI:1760628911
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE PHRMCY #563
Other - Org Type:Doing Business As
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 1:12801 CROSSROADS PKWY S
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3502
Practice Address - Country:US
Practice Address - Phone:866-214-7514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY497693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760628911Medicaid
5633119OtherNCPDP PROVIDER IDENTIFICATION NUMBER