Healthcare Provider Details

I. General information

NPI: 1174826754
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 08/04/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 DOGWOOD DR SE
CONYERS GA
30013-5088
US

IV. Provider business mailing address

1478 DOGWOOD DR SE
CONYERS GA
30013-5088
US

V. Phone/Fax

Practice location:
  • Phone: 678-413-4321
  • Fax: 678-413-4323
Mailing address:
  • Phone: 678-413-4321
  • Fax: 678-413-4323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE009716
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. DIANE SANDERS
Title or Position: PHARMACY COMPLIANCE MANAGER
Credential:
Phone: 770-712-5654