Basic Information
| Provider Information | |||||||||
| NPI: | 1174843544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 707 S GRADY WAY STE 700 | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980573243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532180830 | ||||||||
| FaxNumber: | 2532174306 | ||||||||
| Practice Location | |||||||||
| Address1: | 4705 OLD POST RD UNIT A | ||||||||
| Address2: | |||||||||
| City: | CHARLESTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028131842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017823511 | ||||||||
| FaxNumber: | 4017823499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8154044871 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | PHA00602 | RI | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2125327 | 01 | PK | OTHER |