Provider Demographics
NPI:1215302773
Name:ROUNDYS
Entity type:Organization
Organization Name:ROUNDYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-567-7938
Mailing Address - Street 1:36903 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3144
Mailing Address - Country:US
Mailing Address - Phone:262-567-7938
Mailing Address - Fax:262-567-7994
Practice Address - Street 1:36903 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3144
Practice Address - Country:US
Practice Address - Phone:262-567-7938
Practice Address - Fax:262-567-7994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR9740-40305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36229900Medicaid