Basic Information
Provider Information | |||||||||
NPI: | 1831616655 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 310 W 3RD NORTH ST STE PHARM | ||||||||
Address2: |   | ||||||||
City: | MORRISTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 37814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4235814761 | ||||||||
FaxNumber: | 4239332820 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2017 | ||||||||
LastUpdateDate: | 11/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOHMER | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 2242311833 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X |   |   | Y |   | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2177789 | 01 |   | PK | OTHER |