Provider Demographics
NPI:1174145031
Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Entity type:Organization
Organization Name:AGNESIAN HEALTHCARE ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SYSTEM VP PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-926-6011
Mailing Address - Street 1:145 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3423
Mailing Address - Country:US
Mailing Address - Phone:920-926-6010
Mailing Address - Fax:920-926-6046
Practice Address - Street 1:904 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1201
Practice Address - Country:US
Practice Address - Phone:920-324-8703
Practice Address - Fax:920-324-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33272300Medicaid