Provider Demographics
NPI:1902045479
Name:GENOA COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:GENOA COMMUNITY PHARMACY
Other - Org Name:GENEOA COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-366-1417
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:NE
Mailing Address - Zip Code:68640-0010
Mailing Address - Country:US
Mailing Address - Phone:402-993-2400
Mailing Address - Fax:
Practice Address - Street 1:508 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:NE
Practice Address - Zip Code:68640-3039
Practice Address - Country:US
Practice Address - Phone:402-993-2400
Practice Address - Fax:402-993-2421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE29283336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118928OtherPK
NE10025721600Medicaid