Healthcare Provider Details

I. General information

NPI: 1467818922
Provider Name (Legal Business Name): PUBLIX SUPER MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 OAKHEART RD
MYRTLE BEACH SC
29579-1253
US

IV. Provider business mailing address

PO BOX 639680
CINCINNATI OH
45263-9680
US

V. Phone/Fax

Practice location:
  • Phone: 843-903-4615
  • Fax: 843-492-5492
Mailing address:
  • Phone: 863-688-1188
  • Fax: 863-616-5846

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 Number16386
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2157513
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
IdentifierDE3710
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 3
Identifier716386
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

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