Healthcare Provider Details

I. General information

NPI: 1801834510
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LANCASTER DR NE
SALEM OR
97305-1221
US

IV. Provider business mailing address

2400 LANCASTER DR NE
SALEM OR
97305-1221
US

V. Phone/Fax

Practice location:
  • Phone: 866-280-1563
  • Fax: 503-375-5730
Mailing address:
  • Phone: 866-280-1563
  • Fax: 503-375-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberRP-0000757-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