1639203110 NPI number — PONCE INFECTIOUS DISEASE CENTER PHARMACY

Table of content: (NPI 1639203110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639203110 NPI number — PONCE INFECTIOUS DISEASE CENTER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONCE INFECTIOUS DISEASE CENTER PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639203110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 JESSE HILL JR DR SE
Provider Second Line Business Mailing Address:
PO BOX 26041
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30303-3031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-616-3576
Provider Business Mailing Address Fax Number:
404-616-6070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
341 PONCE DE LEON AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-616-9783
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALLMAN
Authorized Official First Name:
VALAURA
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
404-616-3576

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 855C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GA 7146 . This is a "PHARMACY LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".