Provider Demographics
NPI:1245495480
Name:ROUNDY'S SUPERMARKETS INC
Entity type:Organization
Organization Name:ROUNDY'S SUPERMARKETS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GVP-LEGAL RISK & TREASURY
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:KITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-231-5000
Mailing Address - Street 1:1750 HWY 51 W
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589
Mailing Address - Country:US
Mailing Address - Phone:608-873-3069
Mailing Address - Fax:608-873-3412
Practice Address - Street 1:1750 HWY 51 W
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589
Practice Address - Country:US
Practice Address - Phone:608-873-3069
Practice Address - Fax:608-873-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8850-42333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36229400Medicaid
5130860OtherNCPDP
WI36229400Medicaid