Healthcare Provider Details

I. General information

NPI: 1124462940
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 03/07/2023
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 NW STUCKI AVE
HILLSBORO OR
97124-5806
US

IV. Provider business mailing address

5725 NE 138TH AVE
PORTLAND OR
97230-3409
US

V. Phone/Fax

Practice location:
  • Phone: 866-280-0511
  • Fax: 971-310-3351
Mailing address:
  • Phone: 866-280-0511
  • Fax: 971-310-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number0002241
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number0002771
License Number StateOR

VIII. Authorized Official

Name: ALFRED E. LYMAN JR.
Title or Position: EXEC. DIRECTOR PHARMACY SERVICES
Credential: PHARMD., BCPS
Phone: 503-261-7980