Provider Demographics
NPI:1467408971
Name:JEWEL FOOD STORES INC
Entity Type:Organization
Organization Name:JEWEL FOOD STORES INC
Other - Org Name:JEWEL OSCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NEW STORE ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-916-4463
Mailing Address - Street 1:2355 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2355 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-3033
Practice Address - Country:US
Practice Address - Phone:414-447-8117
Practice Address - Fax:414-447-8365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8057333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33254000Medicaid
5126277OtherOTHER ID NUMBER-COMMERCIAL NUMBER