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	PHY55589	CA
2	3336C0004X	Compounding Pharmacy	PHY55589	CA

General Provider Information

NPI Number	:	1780032623
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	:	6041 CADILLAC AVE
Second Line	:	RM 4644
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-1702
Country	:	US
Telephone Number	:	323-857-4123
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	:	06/01/2016
Last Update Date	:	07/05/2023

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