=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316251598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2010
-----------------------------------------------------
Last Update Date | 08/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6875 DOUGLAS BLVD
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-7133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-2226
-----------------------------------------------------
Fax | 678-838-2231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6875 DOUGLAS BLVD
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-7133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-2226
-----------------------------------------------------
Fax | 678-838-2231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY COMPLIANCE MANAGER
-----------------------------------------------------
Name | MS. DIANE SANDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-712-5654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336M0003X
-----------------------------------------------------
Taxonomy Name | Managed Care Organization Pharmacy
-----------------------------------------------------
License Number | PHRE009688
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------