Healthcare Provider Details

I. General information

NPI: 1588829543
Provider Name (Legal Business Name): ROUNDYS SUPERMARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N ROCHESTER ST
MUKWONAGO WI
53149-8738
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284-2772
US

V. Phone/Fax

Practice location:
  • Phone: 262-363-1680
  • Fax: 262-363-1686
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 Number885342
License Number StateWI

VIII. Authorized Official

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