MEDICARE: PUBLIX NORTH CAROLINA LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy	12973	NC
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2158589	OTHER		PK

General Provider Information

NPI Number	:	1336509363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUBLIX NORTH CAROLINA LP

Provider Business Mailing Address
First Line	:	PO BOX 639680
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-9680
Country	:	US
Telephone Number	:	863-688-1188
Fax Number	:

Provider Business Practice Location Address
First Line	:	1949 HOFFMAN RD
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-6574
Country	:	US
Telephone Number	:	704-853-7004
Fax Number	:

Authorized Official
Title or Position	:	VP PHARMACY
Name	:	DAIN RUSK
Credential	:
Telephone Number	:	863-688-1188

Provider Enumeration Date	:	03/03/2016
Last Update Date	:	01/03/2020

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