Provider Demographics
NPI:1619215290
Name:PUBLIX PHARMACY
Entity Type:Organization
Organization Name:PUBLIX PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLYCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:954-557-3319
Mailing Address - Street 1:1170 WESTON RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1915
Mailing Address - Country:US
Mailing Address - Phone:954-384-7480
Mailing Address - Fax:
Practice Address - Street 1:1170 WESTON RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-1915
Practice Address - Country:US
Practice Address - Phone:954-384-7480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3336C0003X3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy