Healthcare Provider Details

I. General information

NPI: 1982169561
Provider Name (Legal Business Name): GENESIS PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31946 MISSION TRL STE A1
LAKE ELSINORE CA
92530-4539
US

IV. Provider business mailing address

31946 MISSION TRL STE A1
LAKE ELSINORE CA
92530-4539
US

V. Phone/Fax

Practice location:
  • Phone: 559-358-5873
  • Fax:
Mailing address:
  • Phone: 951-245-1373
  • Fax: 877-489-1666

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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: FADY MOSAAD
Title or Position: CEO
Credential:
Phone: 951-245-1373