Basic Information
| Provider Information | |||||||||
| NPI: | 1700951746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAISER FOUNDATION HEALTH PLAN MID ATLANTIC STATES | ||||||||
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| OtherOrganizationName: | LOUDON MEDICAL CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON STREET 3 WEST | ||||||||
| Address2: | KAISER PERMANENT DATA MANAGEMENT DEPARTMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018167446 | ||||||||
| FaxNumber: | 3018167170 | ||||||||
| Practice Location | |||||||||
| Address1: | 19450 DEERFIELD AVENUE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LANSDOWNE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201766821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037262125 | ||||||||
| FaxNumber: | 7037264553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR DATA MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3018185832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| 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.