Provider Demographics
NPI:1326013962
Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Other - Org Name:AGNESIAN PHARMACY WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR RETAIL PHARMACIES
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:HYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:920-926-8723
Mailing Address - Street 1:912 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5530
Mailing Address - Country:US
Mailing Address - Phone:920-929-7480
Mailing Address - Fax:920-929-8779
Practice Address - Street 1:912 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5530
Practice Address - Country:US
Practice Address - Phone:920-929-7480
Practice Address - Fax:920-929-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8435-423336C0003X, 3336C0003X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110220OtherPK
WI33283000Medicaid
WI33283000Medicaid