Provider Demographics
NPI:1326013962
Name:AGNESIAN HEALTHCARE INC
Entity type:Organization
Organization Name:AGNESIAN HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE VICE PRESIDENT WI REGION
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-260-3586
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:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0002X
WI8435-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33283000Medicaid
2110220OtherPK
WI33283000Medicaid