Provider Demographics
NPI:1972826766
Name:GRADY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:GRADY PRATT STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR OF AMBULATORY PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:CHEELEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-616-5711
Mailing Address - Street 1:80 JESSE HILL JR DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3031
Mailing Address - Country:US
Mailing Address - Phone:404-616-5079
Mailing Address - Fax:404-616-8663
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:RM GD032
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-616-5080
Practice Address - Fax:404-616-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2023-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0084303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1159676OtherNCPDP
GA517281744AMedicaid