Healthcare Provider Details

I. General information

NPI: 1982957601
Provider Name (Legal Business Name): GENOA HEALTHCARE OF DELAWARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 8TH ST STE 1
WILMINGTON DE
19801-1408
US

IV. Provider business mailing address

PO BOX 77030
MINNEAPOLIS MN
55480-7730
US

V. Phone/Fax

Practice location:
  • Phone: 253-218-0830
  • Fax: 253-217-4306
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

VIII. Authorized Official

Name: RYAN NIEMEYER
Title or Position: CONTROLLER
Credential:
Phone: 253-218-0830