Provider Demographics
NPI:1598278806
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:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-722-4249
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 1:21 BRIDGEWAY RD STE P
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72113-9514
Practice Address - Country:US
Practice Address - Phone:501-916-4073
Practice Address - Fax:501-246-7658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336L0003X
ARAR208723336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225333407Medicaid
2175872OtherPK