MEDICARE: KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST

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	3336M0003X	Managed Care Organization Pharmacy
3	3336C0002X	Clinic Pharmacy	RP-0000136-CS	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2077258	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366497778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST

Provider Business Mailing Address
First Line	:	4855 SW WESTERN AVE
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-3460
Country	:	US
Telephone Number	:	866-279-1751
Fax Number	:	503-626-4419

Provider Business Practice Location Address
First Line	:	4855 SW WESTERN AVE
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-3460
Country	:	US
Telephone Number	:	866-279-1751
Fax Number	:	503-626-4419

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR, REGIONAL PHARMA
Name	:	ALFRED LYMAN
Credential	:	PHARMD, BCPS
Telephone Number	:	800-813-2000

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	06/01/2021

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Directions to “KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST ” Practice Location

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