Provider Demographics
NPI:1649385675
Name:GENOA HEALTHCARE OF KY LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE OF KY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-639-5088
Mailing Address - Street 1:510 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-2956
Practice Address - Country:US
Practice Address - Phone:270-689-0002
Practice Address - Fax:270-689-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP071313336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1829641OtherOTHER ID NUMBER-COMMERCIAL NUMBER