Organization
KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Active
Other names
KAISER PERMANENTE GWINNETT
Organization subpart
No
Provider details
NPI number
Authorized official
MS. DIANE SANDERS (PHCY COMPLIANCE MGR)
(770) 712-5654
Entity
Organization
Contact information
Practice address
3650 STEVE REYNOLDS BLVD, DULUTH, GA 30096-4506
(770) 931-6134
(770) 931-6403
Mailing address
3650 STEVE REYNOLDS BLVD, DULUTH, GA 30096-4506
(770) 931-6134
(770) 931-6403
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336M0003X
Managed Care Organization Pharmacy
Primary
PHRE07776
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1140956
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
06/22/2006
Last updated
08/04/2021
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