Basic Information
| Provider Information | |||||||||
| NPI: | 1306886734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIX SUPER MARKETS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PUBLIX PHARMACY #0494 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639680 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452639680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881188 | ||||||||
| FaxNumber: | 8636165846 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 N DESHON RD | ||||||||
| Address2: | |||||||||
| City: | STONE MOUNTAIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300874797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708792706 | ||||||||
| FaxNumber: | 7708796513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | RUSK | ||||||||
| AuthorizedOfficialFirstName: | DAIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 8636881188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PHRE007762 | GA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2018949 | 01 | PK | OTHER | 00621222A | 05 | GA | MEDICAID |