Provider Demographics
NPI:1700951746
Name:KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES
Other - Org Name:LOUDON MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR DATA MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-818-5832
Mailing Address - Street 1:2101 E JEFFERSON STREET 3 WEST
Mailing Address - Street 2:KAISER PERMANENT DATA MANAGEMENT DEPARTMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:19450 DEERFIELD AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-6821
Practice Address - Country:US
Practice Address - Phone:703-726-2125
Practice Address - Fax:703-726-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy