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Provider Information for 1023449824


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ROUNDYS SUPERMARKETS INC

Other Names:  
Doing Business As: 
MARIANO'S PHARMACY

Organization Subpart: NO

NPI: 1023449824
Last Updated: 2014-09-08
Certification Date:

Details

NameValue
NPI1023449824
Enumeration Date2013-12-03
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: EDWARD KITZ
Title: GROUP VP - LEGAL RISK & TREASURY
Phone: 4142315000
Mailing Address PO BOX 473
MS-2870
MILWAUKEE, WI 53201-0473
United States

Phone: 414-231-5523 | Fax:
 
Primary Practice Address 950 BROOK FOREST AVE
SHOREWOOD, IL 60404-8846
United States

Phone: 815-577-2747 | Fax:815-577-2751
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Other (non-Medicare)2143377PK
MEDICAIDIL=========019
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyIL054-018487