Provider Demographics
NPI:1922295310
Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Other - Org Name:KAISER PERMENENTE SUGAR HILL BUFORD
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 1:1435 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-5408
Mailing Address - Country:US
Mailing Address - Phone:678-765-5680
Mailing Address - Fax:678-765-5682
Practice Address - Street 1:1435 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5408
Practice Address - Country:US
Practice Address - Phone:678-765-5680
Practice Address - Fax:678-765-5682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0093863336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1156240OtherNCPDP PROVIDER IDENTIFICATION NUMBER