Healthcare Provider Details

I. General information

NPI: 1255523155
Provider Name (Legal Business Name): GENOA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N CENTRAL AVE STE 102
PHOENIX AZ
85004-1818
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 602-257-1133
  • Fax: 602-257-1134
Mailing address:
  • Phone: 877-719-6349
  • Fax: 877-719-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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