Provider Demographics
NPI:1548595416
Name:PUBLIX SUPER MARKETS INC
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS INC
Other - Org Name:PUBLIX PHARMACY #1278
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:863-616-5846
Practice Address - Street 1:955 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-1857
Practice Address - Country:US
Practice Address - Phone:904-819-6774
Practice Address - Fax:904-819-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24291333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001911600Medicaid
2122364OtherPK
2122364OtherPK
PHC056Medicare PIN