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	3336M0003X	Managed Care Organization Pharmacy
2	3336C0002X	Clinic Pharmacy	RP0001106	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2078435	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467491886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST

Provider Business Mailing Address
First Line	:	5125 SKYLINE RD S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97306-9427
Country	:	US
Telephone Number	:	866-280-4583
Fax Number	:	503-588-6579

Provider Business Practice Location Address
First Line	:	5125 SKYLINE RD S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97306-9427
Country	:	US
Telephone Number	:	866-280-4583
Fax Number	:	503-588-6579

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

Provider Enumeration Date	:	06/05/2006
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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