Organization
KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Active
Other names
KAISER PERMANENTE PANOLA
Organization subpart
No
Provider details
NPI number
Authorized official
MS. DIANE SANDERS (PHCY COMPLIANCE MGR)
(770) 712-5654
Entity
Organization
Contact information
Practice address
5440 HILLANDALE DR, LITHONIA, GA 30058-4865
(770) 322-2737
(770) 322-3283
Mailing address
5440 HILLANDALE DR, LITHONIA, GA 30058-4865
(770) 322-2737
(770) 322-3283
Taxonomy
Speciality
Code
Description
License number
State
3336M0003X
Managed Care Organization Pharmacy
Primary
PHRE007143
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1136743
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
08/20/2006
Last updated
08/04/2021
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