Healthcare Provider Details

I. General information

NPI: 1568418069
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN NORTHWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16703 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-4300
US

IV. Provider business mailing address

16703 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-4300
US

V. Phone/Fax

Practice location:
  • Phone: 360-735-5645
  • Fax: 360-735-5646
Mailing address:
  • Phone: 360-735-5645
  • Fax: 360-735-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number05462
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number05462
License Number StateWA

VIII. Authorized Official

Name: JOYCE HUMPHREY
Title or Position: SUPERVISOR
Credential: R.PH.
Phone: 360-735-5274