Provider Demographics
NPI:1457416000
Name:KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC
Other - Org Name:RX CHOICE MAIL ORDER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-5780
Mailing Address - Street 1:22370 DAVIS DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5366
Mailing Address - Country:US
Mailing Address - Phone:703-466-4800
Mailing Address - Fax:703-466-4802
Practice Address - Street 1:1890 METRO CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5276
Practice Address - Country:US
Practice Address - Phone:703-709-1810
Practice Address - Fax:703-709-1688
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy