MEDICARE: GENOA HEALTHCARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy	Y005742	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2137243	OTHER		PK

General Provider Information

NPI Number	:	1093067670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENOA HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 77030
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55480-7730
Country	:	US
Telephone Number	:	253-218-0830
Fax Number	:	253-217-4306

Provider Business Practice Location Address
First Line	:	15317 W BELL RD STE 106
Second Line	:	SUITE 106
City	:	SURPRISE
State	:	AZ
Zip	:	85374-3901
Country	:	US
Telephone Number	:	623-544-5190
Fax Number	:	623-214-5234

Authorized Official
Title or Position	:	CHIEF PHARMACY OFFICER
Name	:	NATASHA HENNESSY
Credential	:
Telephone Number	:	612-722-4249

Provider Enumeration Date	:	10/08/2012
Last Update Date	:	04/26/2021

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