Provider Demographics
NPI:1548597545
Name:ROUNDYS SUPERMARKETS INC
Entity Type:Organization
Organization Name:ROUNDYS SUPERMARKETS INC
Other - Org Name:COPPS FOOD CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PHARMACY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BREDESTEGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
Mailing Address - Street 1:PO BOX 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2772
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:1850 PLOVER RD
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-3921
Practice Address - Country:US
Practice Address - Phone:715-344-0066
Practice Address - Fax:715-344-6909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8967-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1548597545Medicaid
2122741OtherPK
WI1548597545Medicaid