Provider Demographics
NPI:1285042739
Name:PUBLIX PHARMACY #1433
Entity Type:Organization
Organization Name:PUBLIX PHARMACY #1433
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:SENCHYSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:941-705-8785
Mailing Address - Street 1:2438 LAUREL RD E
Mailing Address - Street 2:
Mailing Address - City:NORTH VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34275-3204
Mailing Address - Country:US
Mailing Address - Phone:941-488-2459
Mailing Address - Fax:
Practice Address - Street 1:2438 LAUREL RD E
Practice Address - Street 2:
Practice Address - City:NORTH VENICE
Practice Address - State:FL
Practice Address - Zip Code:34275-3204
Practice Address - Country:US
Practice Address - Phone:941-488-2459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2141338333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009582700OtherMEDICAID FL
FL1356783823OtherNPI
FL80-8012726187-6OtherCONSOLIDATED