Provider Demographics
NPI:1013392281
Name:PUBLIX PHARMACY
Entity Type:Organization
Organization Name:PUBLIX PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-312-3708
Mailing Address - Street 1:301 JOHN GORDON PL
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-7574
Mailing Address - Country:US
Mailing Address - Phone:561-312-3718
Mailing Address - Fax:
Practice Address - Street 1:1109 S PARK ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4462
Practice Address - Country:US
Practice Address - Phone:770-214-3146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0013197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH0013197OtherGA PHARMACIST LICENSE NUMBER