Healthcare Provider Details

I. General information

NPI: 1265825830
Provider Name (Legal Business Name): GENOA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 GA HIGHWAY 96 STE 200A
WARNER ROBINS GA
31088-2584
US

IV. Provider business mailing address

707 S GRADY WAY STE 700
RENTON WA
98057-3243
US

V. Phone/Fax

Practice location:
  • Phone: 478-352-0916
  • Fax: 478-987-2782
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 NumberPHRE010142
License Number StateGA

VIII. Authorized Official

Name: JOSEPH DOUGLAS
Title or Position: CEO
Credential:
Phone: 815-404-4871