Basic Information
| Provider Information | |||||||||
| NPI: | 1215445085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENOA HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 77030 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554807730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532180830 | ||||||||
| FaxNumber: | 2532174306 | ||||||||
| Practice Location | |||||||||
| Address1: | 8441 WAYZATA BLVD, SUITE 340 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527468185 | ||||||||
| FaxNumber: | 9527468187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2018 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | HENNESSY | ||||||||
| AuthorizedOfficialFirstName: | NATASHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF PHARMACY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6127224249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENOA HEALTHCARE LLC | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336M0003X | Y | Suppliers | Pharmacy | Managed Care Organization Pharmacy |
No ID Information.