Healthcare Provider Details

I. General information

NPI: 1386682946
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

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

5725 NE 138TH AVE
PORTLAND OR
97230-3409
US

V. Phone/Fax

Practice location:
  • Phone: 360-571-3072
  • Fax: 360-571-3095
Mailing address:
  • Phone: 503-261-7980
  • Fax: 503-261-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number00005461
License Number StateWA

VIII. Authorized Official

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