Provider Demographics
NPI:1659523363
Name:PUBLIX SUPER MARKETS, INC.
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS, INC.
Other - Org Name:PUBLIX PHARMACY #1313
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:863-688-1188
Mailing Address - Street 1:2381 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4984
Mailing Address - Country:US
Mailing Address - Phone:407-862-5414
Mailing Address - Fax:407-862-5898
Practice Address - Street 1:2381 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4984
Practice Address - Country:US
Practice Address - Phone:407-862-5414
Practice Address - Fax:407-862-5898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1038757OtherNCPDP
FL000731801OtherFLORIDA MEDICAID DME NUMBER
FL000731800Medicaid
1038757OtherNCPDP
PHC056Medicare PIN