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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	PH31328	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2176258	OTHER		PK

General Provider Information

NPI Number	:	1992206254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUBLIX SUPER MARKETS INC

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	:	10015 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-4409
Country	:	US
Telephone Number	:	813-392-4207
Fax Number	:	813-337-6097

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

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	12/06/2019

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