Provider Demographics
NPI:1790850055
Name:KAISER FOUNDATION HEALTH PLAN OF COLORADO
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF COLORADO
Other - Org Name:KAISER PERMANENTE BASELINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENESE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-326-6717
Mailing Address - Street 1:580 MOHAWK DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-3712
Mailing Address - Country:US
Mailing Address - Phone:970-554-5020
Mailing Address - Fax:970-554-5010
Practice Address - Street 1:580 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-3712
Practice Address - Country:US
Practice Address - Phone:970-554-5020
Practice Address - Fax:970-554-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CO900000413336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2003277OtherPK