Provider Demographics
NPI:1184068777
Name:ROUNDYS SUPERMARKETS INC
Entity type:Organization
Organization Name:ROUNDYS SUPERMARKETS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GROUP VP - LEGAL RISK & TREASU
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 1:678 N YORK ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1605
Practice Address - Country:US
Practice Address - Phone:630-782-0031
Practice Address - Fax:630-782-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0182033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140081OtherPK
5305720087Medicare NSC
2140081OtherPK