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Organization Active NPI

Agnesian Healthcare Inc

Doing business as SSM Health Pharmacy

  • Community/Retail Pharmacy
  • Fond Du Lac, WI
National Provider Identifier
1962477588
Registry record updated Feb 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
AGNESIAN HEALTHCARE INC
Doing business as
SSM Health Pharmacy
Practice address
420 E Division St
Fond Du Lac, WI 54935-4560
Phone
(920) 926-8585
Fax
(920) 926-8935
NPI assigned
Feb 17, 2006
Last updated
Feb 7, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 7, 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

420 E Division St
Fond Du Lac, WI 54935-4560

Mailing address

420 E Division St
Fond Du Lac, WI 54935-4560
Phone (920) 926-8585

Other identifiers 2

IdentifierTypeStateIssuer
2109967OtherPK
3359700MedicaidWI

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
O20250513000281 WI DME Supplier - Pharmacy 1658289624 Practice locations: Fond Du Lac, 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
Agnesian Health Care27 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.

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.

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": "1738886400000",
    "number": "1962477588",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-8585",
            "fax_number": "920-926-8935"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "420 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-8585",
            "fax_number": "920-926-8935"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGNESIAN HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-17",
        "last_updated": "2025-02-07",
        "certification_date": "2025-02-07",
        "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": "2109967",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3359700",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fond Du Lac, WI

Sources for this page

Verify at the official NPI Registry.