Healthcare Provider Details

I. General information

NPI: 1639203110
Provider Name (Legal Business Name): PONCE INFECTIOUS DISEASE CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

80 JESSE HILL JR DR SE PO BOX 26041
ATLANTA GA
30303-3031
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-9783
  • Fax:
Mailing address:
  • Phone: 404-616-3576
  • Fax: 404-616-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. VALAURA D. HALLMAN
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 404-616-3576