Provider Demographics
NPI:1083653042
Name:PUBLIX SUPER MARKETS INC
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS INC
Other - Org Name:PUBLIX PHARMACY #0648
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-688-1188
Mailing Address - Street 1:20321 SUMMERLIN RD
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20321 SUMMERLIN RD
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3706
Practice Address - Country:US
Practice Address - Phone:239-454-1704
Practice Address - Fax:239-454-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH0019172333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1098474OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1098474OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0775140544Medicare NSC