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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336L0003X	Long Term Care Pharmacy	PHRE010142	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2153101	OTHER		PK

General Provider Information

NPI Number	:	1265825830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENOA HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	707 S GRADY WAY STE 700
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98057-3243
Country	:	US
Telephone Number	:	253-218-0830
Fax Number	:	253-217-4306

Provider Business Practice Location Address
First Line	:	940 GA HIGHWAY 96 STE 200A
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-2584
Country	:	US
Telephone Number	:	478-352-0916
Fax Number	:	478-987-2782

Authorized Official
Title or Position	:	CEO
Name	:	JOSEPH DOUGLAS
Credential	:
Telephone Number	:	815-404-4871

Provider Enumeration Date	:	03/06/2015
Last Update Date	:	09/15/2022

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Directions to “GENOA HEALTHCARE, LLC ” Practice Location

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