Provider Demographics
NPI:1336607506
Name:KAISER FOUNDATION HEALTH PLAN INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN INC
Other - Org Name:KAISER PERMANENTE DUBLIN MOB PHARMACY #061
Other - Org Type:Other Name
Authorized Official - Title/Position:VP PHARMACY OPERATIONS & SVCS, NCAL
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:RENOUARD
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-625-2363
Mailing Address - Street 1:1800 HARRISON STREET
Mailing Address - Street 2:FLOOR 13
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612
Mailing Address - Country:US
Mailing Address - Phone:510-625-2363
Mailing Address - Fax:
Practice Address - Street 1:3100 DUBLIN BLVD FL 1
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-4363
Practice Address - Country:US
Practice Address - Phone:925-556-5885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-06
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5668883OtherNCPDP
CA1336607506Medicaid