MEDICARE: ROUNDYS SUPERMARKETS 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	9069042	WI

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	2110843	OTHER		PK

General Provider Information

NPI Number	:	1174671432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROUNDYS SUPERMARKETS INC

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	1629 S MAIN ST
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-4935
Country	:	US
Telephone Number	:	262-335-2292
Fax Number	:	262-335-4199

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON BREDESTEGE
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	12/01/2016

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Directions to “ROUNDYS SUPERMARKETS INC ” Practice Location

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