Provider Demographics
NPI:1922281906
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE PHY #193
Other - Org Type:Other Name
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 DEPARTMENT
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 1:17296 SLOVER AVE
Practice Address - Street 2:PALM COURT 1
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7585
Practice Address - Country:US
Practice Address - Phone:909-609-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY488283336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5628827OtherNCPDP PROVIDER IDENTIFICATION NUMBER