Healthcare Provider Details

I. General information

NPI: 1851530950
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STEVE REYNOLDS BLVD
DULUTH GA
30096-4506
US

IV. Provider business mailing address

3650 STEVE REYNOLDS BLVD
DULUTH GA
30096-4506
US

V. Phone/Fax

Practice location:
  • Phone: 770-931-6362
  • Fax: 770-931-6360
Mailing address:
  • Phone: 770-931-6362
  • Fax: 770-931-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHCL000016
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

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