# GENOA HEALTHCARE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Genoa Healthcare
- **Organization subpart:** No

## Provider details

- **NPI number:** 1497713739
- **Authorized official:** RYAN NIEMEYER (CONTROLLER)
- **Authorized official phone:** (253) 218-0830

## Contact information

- **Practice address:** 529 W CENTENNIAL BLVD, SPRINGFIELD, OR 97477-2804
- **Practice address phone:** (541) 868-1682
- **Practice address fax:** (541) 868-1683
- **Mailing address:** PO BOX 77030, MINNEAPOLIS, MN 55480-7730
- **Mailing address phone:** (253) 218-0830
- **Mailing address fax:** (253) 217-4306

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336I0012X | Institutional Pharmacy | 002046 | OR | — |
| 3336L0003X | Long Term Care Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 05/03/2006
- **Last updated:** 04/25/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 005807 | — | OR |
| 05 | — | 231819 | — | OR |
| 01 | — | 3814921 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |