Provider Demographics
NPI:1083629638
Name:GRADY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:GRADY INFECTIOUS DISEASE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:VALAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-616-3576
Mailing Address - Street 1:PHARMACY ADMINISTRATION-26041
Mailing Address - Street 2:80 JESSE HILL JR DRIVE
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303
Mailing Address - Country:US
Mailing Address - Phone:404-616-3576
Mailing Address - Fax:404-616-6070
Practice Address - Street 1:341 PONCE DE LEON AVE NE RM 110
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2012
Practice Address - Country:US
Practice Address - Phone:404-616-2466
Practice Address - Fax:404-616-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GA71463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA937307EMedicaid
2131376OtherPK