Provider Demographics
NPI:1629449541
Name:PUBLIX SUPER MARKETS, INC.
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS, INC.
Other - Org Name:PUBLIX PHARMACY #1497
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSCH
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:863-688-1188
Mailing Address - Fax:
Practice Address - Street 1:831 VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-1901
Practice Address - Country:US
Practice Address - Phone:863-688-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy