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NPI Code Detail

MEDICARE: PUBLIX TENNESSEE LLC

MEDICARE: PUBLIX TENNESSEE LLC
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
1332B00000XDurable Medical Equipment & Medical Supplies
2333600000XPharmacy
33336C0003XCommunity/Retail Pharmacy3866TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22093897OTHERPK
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1366482705
Entity Type Code : Organization
Provider Name (Legal Business Name) : PUBLIX TENNESSEE LLC
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 : 863-616-5846
Provider Business Practice Location Address
First Line : 110 INDIAN LAKE BLVD
Second Line :
City : HENDERSONVILLE
State : TN
Zip : 37075-6206
Country : US
Telephone Number : 615-264-2901
Fax Number : 615-264-6451
Authorized Official
Title or Position : VP PHARMACY
Name : DAIN RUSK
Credential :
Telephone Number : 863-688-1188
Provider Enumeration Date : 06/07/2006
Last Update Date : 01/03/2020

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Directions to “PUBLIX TENNESSEE LLC ” Practice Location

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