Healthcare Provider Details

I. General information

NPI: 1689044414
Provider Name (Legal Business Name): PUBLIX SUPER MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7936 GA HIGHWAY 21
PORT WENTWORTH GA
31407-9720
US

IV. Provider business mailing address

PO BOX 639680
CINCINNATI OH
45263-9680
US

V. Phone/Fax

Practice location:
  • Phone: 912-966-5895
  • Fax: 912-662-8793
Mailing address:
  • Phone: 863-688-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010196
License Number StateGA

VIII. Authorized Official

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