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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5672349	OTHER	CA	NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720607112
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	:	6911 CONVOY CT FL 1 RM 1501
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-1014
Country	:	US
Telephone Number	:	866-385-2632
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	:	04/15/2020
Last Update Date	:	06/14/2023

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