Provider Demographics
NPI:1497713739
Name:GENOA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE, LLC
Other - Org Name:GENOA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-218-0830
Mailing Address - Street 1:PO BOX 77030
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-7730
Mailing Address - Country:US
Mailing Address - Phone:253-218-0830
Mailing Address - Fax:253-217-4306
Practice Address - Street 1:529 W CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2804
Practice Address - Country:US
Practice Address - Phone:541-868-1682
Practice Address - Fax:541-868-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OR0020463336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3814921OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OR005807Medicaid
OR231819Medicaid
3814921OtherNCPDP PROVIDER IDENTIFICATION NUMBER