Basic Information
| Provider Information | |||||||||
| NPI: | 1932120243 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINN DIXIE STORES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINN DIXIE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2209 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322032209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 2629 CRAWFORDVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323272169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509268451 | ||||||||
| FaxNumber: | 8509261170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIMM | ||||||||
| AuthorizedOfficialFirstName: | M. SANDLIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9047835578 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | PH13422 | FL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | PH13422 | FL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 102996701 | 05 | FL | MEDICAID | 102996700 | 05 | FL | MEDICAID | 1075490 | 01 | OTHER ID NUMBER | OTHER |