Provider Demographics
NPI:1023419181
Name:GENOA HEALTHCARE LLC
Entity type:Organization
Organization Name:GENOA HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-231-1833
Mailing Address - Street 1:707 S GRADY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3246
Mailing Address - Country:US
Mailing Address - Phone:253-218-0830
Mailing Address - Fax:253-217-4306
Practice Address - Street 1:23 WARREN ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30317-2201
Practice Address - Country:US
Practice Address - Phone:404-750-4161
Practice Address - Fax:404-378-9298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003152817AMedicaid
2147833OtherPK