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General NPI Number Information
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NPI Number | 1417343120
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Entity Type | Organization
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Legal Business Name | KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
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Dates
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Enumeration Date | 04/09/2015
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Last Update Date | 08/04/2021
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Provider Practice Location Address
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Address Line | 20 GLENLAKE PKWY
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City | ATLANTA
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State | GA
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Zip | 30328-3473
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Country | US
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Telephone | 770-677-6321
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Fax | 770-677-6320
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Provider Business Mailing Address
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Address Line | 20 GLENLAKE PKWY
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City | ATLANTA
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State | GA
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Zip | 30328-3473
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Country | US
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Telephone | 770-677-6321
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Fax | 770-677-6320
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Authorized Official
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Title or Position | PHARMACY COMPLIANCE MANAGER
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Name | MS. DIANE SANDERS
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Credential |
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Telephone | 770-712-5654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | PHCL000028
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License Number State | GA
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