Provider Demographics
NPI:1215976014
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:EXECUTIVE DIRECTOR, REGIONAL PHARMA
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, BCPS
Authorized Official - Phone:800-813-2000
Mailing Address - Street 1:5717 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230
Mailing Address - Country:US
Mailing Address - Phone:503-261-7927
Mailing Address - Fax:503-261-2015
Practice Address - Street 1:5717 NE 138TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3409
Practice Address - Country:US
Practice Address - Phone:503-261-7927
Practice Address - Fax:503-261-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP00002128-CS3336L0003X
WAPHNR.FO.000586583336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2079265OtherPK
OR230431Medicaid
WA6028047Medicaid