Healthcare Provider Details

I. General information

NPI: 1851496160
Provider Name (Legal Business Name): GENOA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 W STATE ST
ROCKFORD IL
61101-1214
US

IV. Provider business mailing address

PO BOX 77030
MINNEAPOLIS MN
55480-7730
US

V. Phone/Fax

Practice location:
  • Phone: 815-962-8192
  • Fax: 815-962-5703
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 Number58013565
License Number StateIL

VIII. Authorized Official

Name: NATASHA HENNESSY
Title or Position: CHIEF PHARMACY OFFICER
Credential:
Phone: 612-722-4249