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
2	3336C0003X	Community/Retail Pharmacy	PH0014308	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2010300	OTHER		PK

General Provider Information

NPI Number	:	1366483869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUBLIX SUPER MARKETS INC

Provider Business Mailing Address
First Line	:	PO BOX 116181
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30368-6181
Country	:	US
Telephone Number	:	863-688-1188
Fax Number	:	863-616-5846

Provider Business Practice Location Address
First Line	:	1910 LAKE WORTH RD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-4228
Country	:	US
Telephone Number	:	561-533-6885
Fax Number	:	561-585-0185

Authorized Official
Title or Position	:	MANAGER OF MANAGED CARE
Name	:	KATIE SCANLON
Credential	:
Telephone Number	:	863-688-1188

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	03/21/2014

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