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NPI Code Detail

MEDICARE: ROUNDYS SUPERMARKETS INC

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
1333600000XPharmacy
23336C0003XCommunity/Retail Pharmacy054-017351IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11484269OTHERNCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number : 1497071823
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 : 414-231-6153
Fax Number : 414-231-5500
Provider Business Practice Location Address
First Line : 802 E NORTHWEST HWY
Second Line :
City : ARLINGTON HEIGHTS
State : IL
Zip : 60004-6233
Country : US
Telephone Number : 847-253-5494
Fax Number : 847-253-5498
Authorized Official
Title or Position : GVP - LEGAL RISK & TREASURY
Name : EDWARD KITZ
Credential :
Telephone Number : 414-231-5000
Provider Enumeration Date : 04/09/2010
Last Update Date : 03/25/2013

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