Provider Demographics
NPI:1982779252
Name:KAISER FOUNDATION HEALTH PLAN OF COLORADO
Entity Type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF COLORADO
Other - Org Name:KAISER PERMANENTE SKYLINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENESE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-326-6717
Mailing Address - Street 1:1375 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205
Mailing Address - Country:US
Mailing Address - Phone:303-764-4669
Mailing Address - Fax:303-764-4662
Practice Address - Street 1:1375 E 20TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5422
Practice Address - Country:US
Practice Address - Phone:303-764-4669
Practice Address - Fax:303-764-4662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CO4083336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2003222OtherPK