Basic Information
| Provider Information | |||||||||
| NPI: | 1225078645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIX SUPER MARKETS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PUBLIX PHARMACY #0545 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116181 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303686181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881188 | ||||||||
| FaxNumber: | 8636165846 | ||||||||
| Practice Location | |||||||||
| Address1: | 11155 TARA BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302281672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704736886 | ||||||||
| FaxNumber: | 7704734716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSCH | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 8636881188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PHRE007931 | GA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 00685748A | 05 | GA | MEDICAID | 2019234 | 01 | PK | OTHER |