Provider Demographics
NPI:1982759569
Name:GENOA HEALTHCARE MINNESOTA
Entity Type:Organization
Organization Name:GENOA HEALTHCARE MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-218-0862
Mailing Address - Street 1:PO BOX 673670
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:253-218-0830
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W
Practice Address - Street 2:SUITE N-464
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:651-917-4029
Practice Address - Fax:651-917-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262961333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy