Healthcare Provider Details

I. General information

NPI: 1982759569
Provider Name (Legal Business Name): GENOA HEALTHCARE MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 UNIVERSITY AVE W SUITE N-464
SAINT PAUL MN
55104-2801
US

IV. Provider business mailing address

PO BOX 673670
DETROIT MI
48267-0001
US

V. Phone/Fax

Practice location:
  • Phone: 651-917-4029
  • Fax: 651-917-4034
Mailing address:
  • Phone: 253-218-0830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number262961
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number262961
License Number StateMN

VIII. Authorized Official

Name: DENISE JASON
Title or Position: CONTRACTS ADMINISTRATOR
Credential:
Phone: 253-218-0862