=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225122633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENOA HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 12/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270 STATE ROUTE 35
-----------------------------------------------------
City | RED BANK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07701-5920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-842-7477
-----------------------------------------------------
Fax | 732-842-7488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 S GRADY WAY STE 400
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98057-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-218-0862
-----------------------------------------------------
Fax | 253-218-0835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | KAREN BOHMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 224-231-1833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------