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	3336C0003X	Community/Retail Pharmacy	054-018499	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2143420	OTHER		PK

General Provider Information

NPI Number	:	1184055980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROUNDYS SUPERMARKETS INC

Provider Business Mailing Address
First Line	:	PO BOX 473
Second Line	:	MS-2870
City	:	MILWAUKEE
State	:	WI
Zip	:	53201-0473
Country	:	US
Telephone Number	:	414-231-5523
Fax Number	:

Provider Business Practice Location Address
First Line	:	5201 N SHERIDAN RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2512
Country	:	US
Telephone Number	:	773-728-7320
Fax Number	:	773-728-0230

Authorized Official
Title or Position	:	GROUP VP - LEGAL RISK & TREASURY
Name	:	EDWARD KITZ
Credential	:
Telephone Number	:	414-231-5000

Provider Enumeration Date	:	12/03/2013
Last Update Date	:	09/08/2014

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