Healthcare Provider Details

I. General information

NPI: 1790724649
Provider Name (Legal Business Name): PUBLIX SUPER MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 ATLANTIC BLVD
NEPTUNE BEACH FL
32266-4000
US

IV. Provider business mailing address

PO BOX 639680
CINCINNATI OH
45263-9680
US

V. Phone/Fax

Practice location:
  • Phone: 904-249-1725
  • Fax: 904-249-0292
Mailing address:
  • Phone: 863-688-1188
  • Fax: 863-616-5846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH0016223
License Number StateFL

VIII. Authorized Official

Name: DAIN RUSK
Title or Position: VP PHARMACY
Credential:
Phone: 863-688-1188