Provider Demographics
NPI:1801227608
Name:ROUNDYS SUPERMARKETS INC
Entity Type:Organization
Organization Name:ROUNDYS SUPERMARKETS INC
Other - Org Name:MARIANO'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP VP - 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:414-231-5523
Mailing Address - Fax:
Practice Address - Street 1:2021 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5549
Practice Address - Country:US
Practice Address - Phone:773-799-9004
Practice Address - Fax:773-799-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0184973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143374OtherPK
IL=========011Medicaid
IL=========011Medicaid
5305720098Medicare NSC