Healthcare Provider Details

I. General information

NPI: 1225078645
Provider Name (Legal Business Name): PUBLIX SUPER MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 TARA BLVD
HAMPTON GA
30228-1672
US

IV. Provider business mailing address

PO BOX 116181
ATLANTA GA
30368-6181
US

V. Phone/Fax

Practice location:
  • Phone: 770-473-6886
  • Fax: 770-473-4716
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 NumberPHRE007931
License Number StateGA

VIII. Authorized Official

Name: JACQUELINE RUSCH
Title or Position: MANAGER OF MANAGED CARE
Credential:
Phone: 863-688-1188