Provider Demographics
NPI:1013427475
Name:GENOA HEALTHCARE LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE LLC
Other - Org Name:GENOA HEALTHCARE, LLC
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 1:800 COMMERCE DR STE 115
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5256
Practice Address - Country:US
Practice Address - Phone:419-931-6383
Practice Address - Fax:567-331-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336L0003X
OHPMY.022863300-03336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0271416Medicaid
2176531OtherPK