Healthcare Provider Details

I. General information

NPI: 1548595416
Provider Name (Legal Business Name): PUBLIX SUPER MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 STATE ROAD 16
ST AUGUSTINE FL
32084-1857
US

IV. Provider business mailing address

PO BOX 639680
CINCINNATI OH
45263-9680
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-6774
  • Fax: 904-819-6872
Mailing address:
  • Phone: 863-688-1188
  • Fax: 863-616-5846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH24291
License Number StateFL

VIII. Authorized Official

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