Provider Demographics
NPI:1124462940
Name:KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Entity type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC. DIRECTOR PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD, BCPS
Authorized Official - Phone:503-261-7980
Mailing Address - Street 1:5725 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3409
Mailing Address - Country:US
Mailing Address - Phone:866-280-0511
Mailing Address - Fax:971-310-3351
Practice Address - Street 1:2875 NW STUCKI AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5806
Practice Address - Country:US
Practice Address - Phone:866-280-0511
Practice Address - Fax:971-310-3351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00027713336M0003X
OR00022413336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3844708OtherNCPDP
ORRP-0002771-CSOtherBOP LICENSE
WA2038157Medicaid
OR50065832Medicaid
OR50065832Medicaid