Basic Information
Provider Information
NPI: 1184148926
EntityType: 2
ReplacementNPI:  
OrganizationName: GENOA HEALTHCARE, LLC
LastName:  
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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: 149 THOMPSON AVE E STE 150
Address2:  
City: WEST ST PAUL
State: MN
PostalCode: 551183238
CountryCode: US
TelephoneNumber: 6122842130
FaxNumber: 6123516893
Other Information
ProviderEnumerationDate: 08/02/2017
LastUpdateDate: 10/28/2022
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: BOHMER
AuthorizedOfficialFirstName: KAREN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: SECRETARY
AuthorizedOfficialTelephone: 2242311833
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate: 10/28/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X  N SuppliersDurable Medical Equipment & Medical Supplies 
333600000X  N SuppliersPharmacy 
3336C0003X  N SuppliersPharmacyCommunity/Retail Pharmacy
3336L0003X  Y SuppliersPharmacyLong Term Care Pharmacy

ID Information
IDTypeStateIssuerDescription
FG694711501 DEAOTHER
26537601MNSTATE BOARD OF PHARMACYOTHER


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