Provider Demographics
NPI:1801041900
Name:PUBLIX TENNESSEE LLC
Entity Type:Organization
Organization Name:PUBLIX TENNESSEE LLC
Other - Org Name:PUBLIX PHARMACY #1244
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 1:5958 SNOW HILL RD STE 168
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-7834
Practice Address - Country:US
Practice Address - Phone:423-238-2105
Practice Address - Fax:423-910-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
TN4584333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117892OtherPK
4604230028Medicare NSC
PHC054Medicare PIN