Provider Demographics
NPI:1730380452
Name:KAISER PERMANENTE
Entity type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:650-301-5781
Mailing Address - Street 1:395 HICKEY BLVD
Mailing Address - Street 2:1ST FLOOR PHARMACY
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2770
Mailing Address - Country:US
Mailing Address - Phone:650-301-5700
Mailing Address - Fax:650-301-5780
Practice Address - Street 1:395 HICKEY BLVD
Practice Address - Street 2:1ST FLOOR PHARMACY
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2770
Practice Address - Country:US
Practice Address - Phone:650-301-5700
Practice Address - Fax:650-301-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA465653336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA465650OtherMEDI-CAL PROVIDER NUMBER