MEDICARE: PUBLIX SUPER MARKETS INC

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	333600000X	Pharmacy	PH0013159	FL
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1074361	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1346280724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUBLIX SUPER MARKETS INC

Provider Business Mailing Address
First Line	:	1660 TAYLOR RD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6753
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 TAYLOR RD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6753
Country	:	US
Telephone Number	:	386-756-6175
Fax Number	:	386-756-3985

Authorized Official
Title or Position	:	CONTRACT ADMINISTRATOR
Name	:	SARAH POPE
Credential	:
Telephone Number	:	863-688-1188

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	12/06/2007

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Directions to “PUBLIX SUPER MARKETS INC ” Practice Location

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