1245495480 NPI number — ROUNDY'S SUPERMARKETS INC

Table of content: (NPI 1245495480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245495480 NPI number — ROUNDY'S SUPERMARKETS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROUNDY'S SUPERMARKETS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245495480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1750 HWY 51 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOUGHTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-873-3069
Provider Business Mailing Address Fax Number:
608-873-3412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1750 HWY 51 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-873-3069
Provider Business Practice Location Address Fax Number:
608-873-3412
Provider Enumeration Date:
07/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KITZ
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
GVP-LEGAL RISK & TREASURY
Authorized Official Telephone Number:
414-231-5000

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  8850-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36229400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5130860 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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