Healthcare Provider Details

I. General information

NPI: 1407803513
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 N INTERSTATE AVE
PORTLAND OR
97227-1106
US

IV. Provider business mailing address

3600 N INTERSTATE AVE
PORTLAND OR
97227-1106
US

V. Phone/Fax

Practice location:
  • Phone: 503-331-6570
  • Fax: 503-331-6575
Mailing address:
  • Phone: 503-331-6570
  • Fax: 503-331-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHNR.FO.60658960
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberRP-0001284-CS
License Number StateOR

VIII. Authorized Official

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