Provider Demographics
NPI:1427373224
Name:GRADY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:GRADY MEMORIAL HOSP CORP-CENTRAL REFILL PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHARMACY ADMINISTRATION
Authorized Official - Prefix:MS
Authorized Official - First Name:VALAURA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:404-616-3576
Mailing Address - Street 1:PO BOX 26041
Mailing Address - Street 2:80 JESSE HILL JR DRIVE SE
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-0001
Mailing Address - Country:US
Mailing Address - Phone:404-616-3576
Mailing Address - Fax:404-616-6070
Practice Address - Street 1:1575 NORTHSIDE DR NW BLDG 400
Practice Address - Street 2:ATLANTA TECH CENTER SUITE 450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-4235
Practice Address - Country:US
Practice Address - Phone:404-616-0930
Practice Address - Fax:404-616-6070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0096483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA556337752AMedicaid
1159652OtherNCPDP