Provider Demographics
NPI:1437553625
Name:PUBLIX
Entity type:Organization
Organization Name:PUBLIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-366-9720
Mailing Address - Street 1:4250 ALAFAYA TRL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4250 ALAFAYA TRL
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9412
Practice Address - Country:US
Practice Address - Phone:407-366-9720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52695183500000X
1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty