Provider Demographics
NPI:1447487574
Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Entity type:Organization
Organization Name:KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-712-5654
Mailing Address - Street 1:1400 NORTHSIDE FORSYTH DR STE 350
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6018
Mailing Address - Country:US
Mailing Address - Phone:404-364-4824
Mailing Address - Fax:404-949-5242
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR STE 350
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6018
Practice Address - Country:US
Practice Address - Phone:404-364-4824
Practice Address - Fax:404-949-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0095843336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1158840OtherNCPDP PROVIDER IDENTIFICATION NUMBER