Basic Information
| Provider Information | |||||||||
| NPI: | 1609934181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENSINGTON MEDICAL CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22370 DAVIS DR | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | STERLING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201645366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034664800 | ||||||||
| FaxNumber: | 7034664802 | ||||||||
| Practice Location | |||||||||
| Address1: | 10810 CONNECTICUT AVENUE | ||||||||
| Address2: | |||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208952138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019297175 | ||||||||
| FaxNumber: | 3019297360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | DEANNE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3018165760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES,INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0003X | Y | Suppliers | Pharmacy | Managed Care Organization Pharmacy |
No ID Information.