Provider Demographics
NPI:1013289610
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:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-231-1833
Mailing Address - Street 1:707 S GRADY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3246
Mailing Address - Country:US
Mailing Address - Phone:253-218-0830
Mailing Address - Fax:253-217-4306
Practice Address - Street 1:2662 ELMWOOD RD
Practice Address - Street 2:STE. 101
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1573
Practice Address - Country:US
Practice Address - Phone:815-516-0246
Practice Address - Fax:815-639-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL320.010221OtherCONTROLLED SUBSTANCE #
IL054.017839OtherPHARMACY LICENSE #
1486491OtherNCPDP #
1486491OtherNCPDP #