Provider Demographics
NPI:1790997773
Name:HEALTHSPAN INTEGRATED CARE
Entity Type:Organization
Organization Name:HEALTHSPAN INTEGRATED CARE
Other - Org Name:KAISER FOUNDATION HEALTH PLAN PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MGR, PHARM BUSINESS
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:216-778-6050
Mailing Address - Street 1:5420 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44131-1832
Mailing Address - Country:US
Mailing Address - Phone:216-749-8408
Mailing Address - Fax:216-749-8426
Practice Address - Street 1:10 SEVERANCE CIR
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1533
Practice Address - Country:US
Practice Address - Phone:216-297-3803
Practice Address - Fax:216-297-2769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020338503336C0002X
OH0200338503336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy