Basic Information
| Provider Information | |||||||||
| NPI: | 1134889314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIX SUPER MARKETS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PUBLIX PHARMACY #0727 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 639680 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452639680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 171 TOWN AND COUNTRY DR | ||||||||
| Address2: | |||||||||
| City: | PALATKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321773962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866436234 | ||||||||
| FaxNumber: | 3865304072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2021 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSK | ||||||||
| AuthorizedOfficialFirstName: | DAIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 8636881188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.