Provider Demographics
NPI:1609815570
Name:PUBLIX SUPER MARKETS INC
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS INC
Other - Org Name:PUBLIX PHARMACY #0292
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-688-1188
Mailing Address - Street 1:7060 W PALMETTO PARK RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7060 W PALMETTO PARK RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3411
Practice Address - Country:US
Practice Address - Phone:561-447-6959
Practice Address - Fax:561-447-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH0018494333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1095187OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PHC056Medicare PIN
0775140484Medicare NSC