Provider Demographics
NPI:1013454545
Name:GENESIS RECOVERY SERVICES, LLC
Entity Type:Organization
Organization Name:GENESIS RECOVERY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:MELBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:218-740-2345
Mailing Address - Street 1:5 N 3RD AVE W STE 302
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1614
Mailing Address - Country:US
Mailing Address - Phone:218-740-2345
Mailing Address - Fax:
Practice Address - Street 1:5 N 3RD AVE W STE 302
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1614
Practice Address - Country:US
Practice Address - Phone:218-740-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN265250333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy