Healthcare Provider Details

I. General information

NPI: 1639317324
Provider Name (Legal Business Name): ROUNDYS SUPERMARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 S 27TH ST
MILWAUKEE WI
53221-1304
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284-2772
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-3622
  • Fax: 414-281-5529
Mailing address:
  • Phone: 513-762-1019
  • Fax: 513-762-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8913-042
License Number StateWI

VIII. Authorized Official

Name: ALLISON BREDESTEGE
Title or Position: MANAGER OF PHARMACY LICENSING
Credential:
Phone: 513-762-1019