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	PHY49884	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	5634224	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1104060383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN INC

Provider Business Mailing Address
First Line	:	12254 BELLFLOWER BLVD
Second Line	:	PHARM PROFESSIONAL AFFAIRS FLOOR 2
City	:	OAKLAND
State	:	CA
Zip	:	94611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 BROADWAY FL 4
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94611-5613
Country	:	US
Telephone Number	:	562-658-3671
Fax Number	:

Authorized Official
Title or Position	:	NAT'L VP PHRMCY PROG & SVCS
Name	:	DAVID KVANCZ
Credential	:
Telephone Number	:	562-658-3510

Provider Enumeration Date	:	05/01/2009
Last Update Date	:	01/25/2011

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