Provider Demographics
NPI:1891843157
Name:ROUNDYS SUPERMARKETS INC
Entity Type:Organization
Organization Name:ROUNDYS SUPERMARKETS INC
Other - Org Name:PICK N SAVE 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:G
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 1300
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-0473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 63RD ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4467
Practice Address - Country:US
Practice Address - Phone:262-653-0169
Practice Address - Fax:262-564-8840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86630423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33289400Medicaid
5131266OtherNCPDP
5305720004Medicare NSC
000001649Medicare PIN