Provider Demographics
NPI:1235519455
Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Other - Org Name:AGNESIAN PRESCRIPTION CENTER HEALTH PLAZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR-RETAIL PHARMACY SERVI
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:HYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-8723
Mailing Address - Street 1:421 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8335
Mailing Address - Country:US
Mailing Address - Phone:920-926-5455
Mailing Address - Fax:920-926-8838
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-926-5455
Practice Address - Fax:920-926-8838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8107-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152190OtherPK