Provider Demographics
NPI:1548719271
Name:GENEVA PHARMACY LLC
Entity type:Organization
Organization Name:GENEVA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:402-281-1956
Mailing Address - Street 1:20513 NICHOLAS CIR STE 3
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-2971
Mailing Address - Country:US
Mailing Address - Phone:402-759-9104
Mailing Address - Fax:402-718-9421
Practice Address - Street 1:20513 NICHOLAS CIR STE 3
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-2971
Practice Address - Country:US
Practice Address - Phone:402-759-9104
Practice Address - Fax:402-718-9421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NE6773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164318OtherPK