Provider Demographics
NPI:1972736932
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 OPERATIONS
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:503-261-7566
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:503-261-7939
Mailing Address - Fax:503-261-7567
Practice Address - Street 1:11200 SW MURRAY SCHOLLS PL
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9702
Practice Address - Country:US
Practice Address - Phone:866-331-8041
Practice Address - Fax:503-590-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-2556-CS3336C0002X
3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500611998Medicaid
3843679OtherNCPDP PROVIDER IDENTIFICATION NUMBER