Healthcare Provider Details

I. General information

NPI: 1902045479
Provider Name (Legal Business Name): GENOA COMMUNITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 WILLARD AVE
GENOA NE
68640-3039
US

IV. Provider business mailing address

PO BOX 10
GENOA NE
68640-0010
US

V. Phone/Fax

Practice location:
  • Phone: 402-993-2400
  • Fax: 402-993-2421
Mailing address:
  • Phone: 402-993-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2928
License Number StateNE

VIII. Authorized Official

Name: ROBERT BAILEY
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 402-366-1417