MEDICARE: KAISER FOUNDATION HEALTH PLAN INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY40710	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0525571	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1063569382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN INC

Provider Business Mailing Address
First Line	:	12254 BELLFLOWER BLVD FL 2
Second Line	:	PHARMACY OPERATIONS
City	:	DOWNEY
State	:	CA
Zip	:	90242-2804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 E 4TH ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-3910
Country	:	US
Telephone Number	:	866-353-5060
Fax Number	:

Authorized Official
Title or Position	:	VP PHARMACY OPERATIONS & SVCS, SCAL
Name	:	RHONDA LEE POLCHAK
Credential	:
Telephone Number	:	562-658-3510

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	06/22/2023

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