Provider Demographics
NPI:1750610515
Name:PUBLIX TENNESSEE LLC
Entity type:Organization
Organization Name:PUBLIX TENNESSEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:665 SOUTH MT.JULIET RD.
Practice Address - Street 2:
Practice Address - City:MT. JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122
Practice Address - Country:US
Practice Address - Phone:615-773-0255
Practice Address - Fax:615-903-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
TN4715333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123032OtherPK
2123032OtherPK
4604230029Medicare NSC