Provider Demographics
NPI:1831495803
Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Other - Org Name:KAISER PERMANENTE FAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY COMPLIANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-712-5654
Mailing Address - Street 1:101 BANKS STA
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7507
Mailing Address - Country:US
Mailing Address - Phone:678-610-3701
Mailing Address - Fax:678-610-3703
Practice Address - Street 1:101 BANKS STA
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7507
Practice Address - Country:US
Practice Address - Phone:678-610-3701
Practice Address - Fax:678-610-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0097313336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127407OtherPK