NPIMap

Organization Active NPI

Agnesian Healthcare Inc

  • Community/Retail Pharmacy
  • Waupun, WI
National Provider Identifier
1366417917
Registry record updated Jul 23, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
AGNESIAN HEALTHCARE INC
Practice address
904 W Main St
Waupun, WI 53963-1201
Phone
(920) 324-3010
Fax
(920) 324-3875
NPI assigned
Feb 17, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 23, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amy Jo Grinnell
Title
Finance Vice President Wi Region
Phone
(608) 260-3586

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X Primary

Addresses

Primary practice location

904 W Main St
Waupun, WI 53963-1201

Mailing address

904 W Main St
Waupun, WI 53963-1201
Phone (920) 324-3010

Other identifiers 3

IdentifierTypeStateIssuer
2113944OtherPK
33272300MedicaidWI
100317609MedicaidWI

Other names 1

  • SSM Health Pharmacy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20250213002665 WI Part B Supplier - Mass Immunization (Roster Biller Only) 1658289624 3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fond Du Lac, WI; Waupun, WI
O20250515000014 WI DME Supplier - Pharmacy 1658289624 Practice locations: Waupun, WI

Other NPIs with the same Medicare PAC ID 16

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 16

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Fond Du Lac Regional CL27 organizations share this tax ID, including this one

Other organizations with this tax ID 26

Organizations that report the same tax identification number in the National Provider Directory.

View all 26

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

200 Front St
#3D
Beaver Dam, WI 53916
Phone (920) 885-2780

250 Corporate Dr
Beaver Dam, WI 53916
Phone (920) 887-6650

110 Monroe St
Beaver Dam, WI 53916
Phone (920) 887-3376

112 Monroe St
Beaver Dam, WI 53916
Phone (920) 926-8573

101 S Pioneer Rd
Fond du Lac, WI 54935
Phone (920) 923-2333

40 Camelot Dr
Fond du Lac, WI 54935
Phone (920) 907-8201

305 Camelot Dr
Fond du Lac, WI 54935
Phone (920) 923-2333

649 Fond du Lac Ave
Fond du Lac, WI 54935
Phone (920) 322-8700

54 W Arndt St
Fond du Lac, WI 54935
Phone (920) 921-9520

745 South St
Ste 4
Green Lake, WI 54941
Phone (920) 294-6220

1091 Horicon St
Mayville, WI 53050
Phone (920) 387-3267

100 Evergreen Rd
Mount Calvary, WI 53057
Phone (920) 753-2311

N8120 County Road WW
Mount Calvary, WI 53057
Phone (920) 753-3015

501 S Main St
Oshkosh, WI 54902
Phone (920) 232-1672

6412 Bonnie View Rd
Pickett, WI 54964
Phone (920) 589-5014

500 S High St
Randolph, WI 53956
Phone (920) 326-3171

632 Hilltop Ln
Ripon, WI 54971
Phone (920) 748-2999

904 W Main St
Waupun, WI 53963
Phone (920) 324-3010

910 W Main St
Waupun, WI 53963
Phone (920) 324-3010

601 Buwalda Dr
Waupun, WI 53963
Phone (920) 324-2924

620 W Brown St
Ste 4
Waupun, WI 53963
Phone (920) 926-8332

1000 W Brown St
Waupun, WI 53963
Phone (920) 324-6560

608 W Brown St
Waupun, WI 53963
Phone (920) 324-6800

N6581 Villa Pkwy
Westfield, WI 53964
Phone (608) 296-3190

Ownership & related parties

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
SSM Health Waupun Memorial HospitalWaupun, WI, CCN 52Z327 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2000
SSM Health Ripon Community HospitalRipon, WI, CCN 521321 Hospital 5% Or Greater Direct Ownership Interest (100%) Jun 1, 2011
SSM Health Ripon Community HospitalRipon, WI, CCN 52Z321 Hospital 5% Or Greater Direct Ownership Interest (100%) Jun 1, 2011
St Francis HomeFond Du Lac, WI, CCN 525595 Skilled nursing facility Operational/Managerial Control Jun 1, 1978

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 640

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 640

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1140134400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1753228800000",
    "number": "1366417917",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "904 W MAIN ST",
            "city": "WAUPUN",
            "state": "WI",
            "postal_code": "539631201",
            "telephone_number": "920-324-3010",
            "fax_number": "920-324-4370"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "904 W MAIN ST",
            "city": "WAUPUN",
            "state": "WI",
            "postal_code": "539631201",
            "telephone_number": "920-324-3010",
            "fax_number": "920-324-3875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGNESIAN HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-17",
        "last_updated": "2025-07-23",
        "certification_date": "2025-07-23",
        "status": "A",
        "authorized_official_last_name": "GRINNELL",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "JO",
        "authorized_official_title_or_position": "FINANCE VICE PRESIDENT WI REGION",
        "authorized_official_telephone_number": "608-260-3586"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2113944",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33272300",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100317609",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waupun, WI

Sources for this page

Verify at the official NPI Registry.