Healthcare Provider Details

I. General information

NPI: 1083629638
Provider Name (Legal Business Name): GRADY MEMORIAL HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 PONCE DE LEON AVE NE RM 110
ATLANTA GA
30308-2012
US

IV. Provider business mailing address

PHARMACY ADMINISTRATION-26041 80 JESSE HILL JR DRIVE
ATLANTA GA
30303
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-2466
  • Fax: 404-616-9777
Mailing address:
  • Phone: 404-616-3576
  • Fax: 404-616-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7146
License Number StateGA

VIII. Authorized Official

Name: VALAURA HALLMAN
Title or Position: DIRECTOR OF PHARMACY ADMINISTRATION
Credential:
Phone: 404-616-3576