Provider Demographics
NPI:1578107561
Name:PUBLIX SUPER MARKETS, INC.
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS, INC.
Other - Org Name:PUBLIX PHARMACY #1561
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 407
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-0407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 NW NORTH RIVER DR STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-2889
Practice Address - Country:US
Practice Address - Phone:786-988-6447
Practice Address - Fax:786-522-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-01
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy