Provider Demographics
NPI:1962477588
Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Other - Org Name:AGNESIAN PHARMACY PLUS
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:
Authorized Official - Phone:920-926-8723
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8585
Mailing Address - Fax:920-926-8935
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8585
Practice Address - Fax:920-926-8935
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
333600000X
WI8107-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2109967OtherPK
WI3359700Medicaid
WI3359700Medicaid