Provider Demographics
NPI:1497071823
Name:ROUNDYS SUPERMARKETS INC
Entity Type:Organization
Organization Name:ROUNDYS SUPERMARKETS INC
Other - Org Name:MARIANOS FRESH MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GVP - LEGAL RISK & TREASURY
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-231-5000
Mailing Address - Street 1:PO BOX 473
Mailing Address - Street 2:MS-2870
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-0473
Mailing Address - Country:US
Mailing Address - Phone:414-231-6153
Mailing Address - Fax:414-231-5500
Practice Address - Street 1:802 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-6233
Practice Address - Country:US
Practice Address - Phone:847-253-5494
Practice Address - Fax:847-253-5498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054-0173513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1484269OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========001Medicaid
5305720051Medicare NSC