Basic Information
| Provider Information | |||||||||
| NPI: | 1154823615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIX NORTH CAROLINA LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PUBLIX PHARMACY #1632 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639680 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452639680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9601 PATRIOT HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224079407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403766212 | ||||||||
| FaxNumber: | 5403221746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSK | ||||||||
| AuthorizedOfficialFirstName: | DAIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 8636881188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/07/2022 | ||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | 2178027 | 01 | PK | OTHER |