Healthcare Provider Details

I. General information

NPI: 1750708657
Provider Name (Legal Business Name): GENOA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 LAUREL ST STE 102
ANCHORAGE AK
99508-5392
US

IV. Provider business mailing address

707 S GRADY WAY STE 400
RENTON WA
98057-3246
US

V. Phone/Fax

Practice location:
  • Phone: 907-891-7079
  • Fax: 907-331-3147
Mailing address:
  • Phone: 253-218-0830
  • Fax: 253-217-4306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KAREN BOHMER
Title or Position: SECRETARY
Credential:
Phone: 224-231-1833