Provider Demographics
NPI:1740220607
Name:PUBLIX SUPER MARKETS INC
Entity Type:Organization
Organization Name:PUBLIX SUPER MARKETS INC
Other - Org Name:PUBLIX PHARMACY #1043
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 639680
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9680
Mailing Address - Country:US
Mailing Address - Phone:863-688-1188
Mailing Address - Fax:863-616-5846
Practice Address - Street 1:1425 MARKET BLVD STE 600
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6711
Practice Address - Country:US
Practice Address - Phone:770-640-6088
Practice Address - Fax:770-640-6362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0089603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA046256588AMedicaid
2016110OtherPK
GA046256588AMedicaid
0775140653Medicare NSC