Provider Demographics
NPI:1366483869
Name:PUBLIX SUPER MARKETS INC
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS INC
Other - Org Name:PUBLIX PHARMACY #0143
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCANLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-688-1188
Mailing Address - Street 1:PO BOX 116181
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6181
Mailing Address - Country:US
Mailing Address - Phone:863-688-1188
Mailing Address - Fax:863-616-5846
Practice Address - Street 1:1910 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4228
Practice Address - Country:US
Practice Address - Phone:561-533-6885
Practice Address - Fax:561-585-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH00143083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105410400Medicaid
2010300OtherPK
2010300OtherPK
PHC056Medicare PIN