Provider Demographics
NPI:1639203110
Name:PONCE INFECTIOUS DISEASE CENTER PHARMACY
Entity Type:Organization
Organization Name:PONCE INFECTIOUS DISEASE CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
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 1:80 JESSE HILL JR DR SE
Mailing Address - Street 2:PO BOX 26041
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3031
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
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:404-616-9783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA855CMedicaid
GAGA 7146OtherPHARMACY LICENSE
GAGA 7146OtherPHARMACY LICENSE