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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
13336C0003XCommunity/Retail Pharmacy8964-42WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22122740OTHERPK

General Provider Information

NPI Number : 1902133903
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 : 250 W HOLT AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53207-3200
Country : US
Telephone Number : 414-769-8990
Fax Number : 414-769-8997
Authorized Official
Title or Position : MANAGER OF PHARMACY LICENSING
Name : ALLISON BREDESTEGE
Credential :
Telephone Number : 513-762-1019
Provider Enumeration Date : 11/11/2009
Last Update Date : 12/01/2016

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