Provider Demographics
NPI:1366540239
Name:GENOA HEALTHCARE OF FLORIDA, LLC
Entity type:Organization
Organization Name:GENOA HEALTHCARE OF FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-218-0830
Mailing Address - Street 1:PO BOX 77030
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-7730
Mailing Address - Country:US
Mailing Address - Phone:253-218-0830
Mailing Address - Fax:253-217-4306
Practice Address - Street 1:1437 S BELCHER RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-2829
Practice Address - Country:US
Practice Address - Phone:727-533-9073
Practice Address - Fax:727-533-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X, 3336C0003X
FLPH221023336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031630000Medicaid
1020356OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FLPH22102OtherBOP LICENSE
FLPH22102OtherBOP LICENSE
5797520007Medicare NSC