Provider Demographics
NPI:1609425826
Name:PUBLIX SUPER MARKETS, INC.
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS, INC.
Other - Org Name:PUBLIX PHARMACY #1684
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 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:
Practice Address - Street 1:155 BARTRAM PARK DRIVE, SUITE 100
Practice Address - Street 2:
Practice Address - City:ST. JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:160-942-5826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy