Healthcare Provider Details

I. General information

NPI: 1790113371
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 7TH AVE.
LONGVIEW WA
98682
US

IV. Provider business mailing address

5725 NE 138TH AVE.
PORTLAND OR
97230-3409
US

V. Phone/Fax

Practice location:
  • Phone: 866-279-8943
  • Fax: 360-636-6271
Mailing address:
  • Phone: 503-261-2166
  • Fax: 503-261-2166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHAR.CF.60362983
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STEVE LOGAN
Title or Position: EXEC. DIRECTOR PHARMACY SERVICES
Credential: RPH
Phone: 503-261-7566