Healthcare Provider Details

I. General information

NPI: 1407893407
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10100 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

V. Phone/Fax

Practice location:
  • Phone: 866-280-1228
  • Fax: 503-571-2789
Mailing address:
  • Phone: 866-280-1228
  • Fax: 503-571-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberRP-0001088-CS
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ALFRED LYMAN
Title or Position: EXECUTIVE DIRECTOR, REGIONAL PHARMA
Credential: PHARMD, BCPS
Phone: 800-813-2000