Healthcare Provider Details

I. General information

NPI: 1497713739
Provider Name (Legal Business Name): GENOA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 W CENTENNIAL BLVD
SPRINGFIELD OR
97477-2804
US

IV. Provider business mailing address

PO BOX 77030
MINNEAPOLIS MN
55480-7730
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-1682
  • Fax: 541-868-1683
Mailing address:
  • Phone: 253-218-0830
  • Fax: 253-217-4306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number002046
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
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