Provider Demographics
NPI:1497345573
Name:PUBLIX TENNESSEE, LLC
Entity Type:Organization
Organization Name:PUBLIX TENNESSEE, LLC
Other - Org Name:PUBLIX PHARMACY 1633
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-688-1188
Mailing Address - Street 1:PO BOX 639680
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9680
Mailing Address - Country:US
Mailing Address - Phone:863-688-1188
Mailing Address - Fax:
Practice Address - Street 1:509 N STATE OF FRANKLIN RD STE 20
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8215
Practice Address - Country:US
Practice Address - Phone:423-328-5119
Practice Address - Fax:423-328-1138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-22
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy