Organization
GENOA HEALTHCARE, LLC
Active
Other names
Genoa Healthcare
Organization subpart
No
Provider details
NPI number
Authorized official
RYAN NIEMEYER (CONTROLLER)
(253) 218-0830
Entity
Organization
Contact information
Practice address
325 E PIONEER AVE, SUITE B-124, PUYALLUP, WA 98372-3265
(253) 770-7000
(253) 770-7018
Mailing address
PO BOX 77030, MINNEAPOLIS, MN 55480-7730
(253) 218-0830
(253) 217-4306
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336L0003X
Long Term Care Pharmacy
Primary
CF57740
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4930601
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
6027031
—
WA
Enumeration date
05/03/2006
Last updated
04/25/2012
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