Provider Demographics
NPI:1861449043
Name:GENESIS HEALTHCARE SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTHCARE SYSTEM
Other - Org Name:GENESIS ROSEVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-454-4773
Mailing Address - Street 1:133 N MAYSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-6112
Mailing Address - Country:US
Mailing Address - Phone:740-454-5666
Mailing Address - Fax:740-452-7563
Practice Address - Street 1:157 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43777-1238
Practice Address - Country:US
Practice Address - Phone:740-697-0348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
OH02-7077003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0232000344OtherSTATE LICENSE
OH0887901Medicaid