Provider Demographics
NPI:1023367711
Name:GENOA HEALTHCARE LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-231-1833
Mailing Address - Street 1:707 S GRADY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3246
Mailing Address - Country:US
Mailing Address - Phone:253-218-0830
Mailing Address - Fax:253-217-4306
Practice Address - Street 1:1902 OLDE HOMESTEAD LANE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2137
Practice Address - Country:US
Practice Address - Phone:717-723-9910
Practice Address - Fax:717-393-3951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
PAPP4823393336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136846OtherPK
3998006OtherNCPDP
PAFG5598000OtherDEA