Provider Demographics
NPI:1356711089
Name:PUBLIX
Entity type:Organization
Organization Name:PUBLIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-206-7993
Mailing Address - Street 1:4065 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-4294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4065 HANCOCK BRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-4294
Practice Address - Country:US
Practice Address - Phone:239-997-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16290175953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS54008OtherREGISTERED PHARMACIST