# DOUGLAS & OGDEN MEDICAL CENTER PHARMACY INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Main Street Pharmacy, DOUGLAS MAIN PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1760543581
- **Authorized official:** DR. CLARKE ALLAN KUELTZO PHARMD (PRESIDENT)
- **Authorized official phone:** (630) 969-0036

## Contact information

- **Practice address:** 24 W FIRST ST, MANTENO, IL 60950-1239
- **Practice address phone:** (630) 969-0036
- **Practice address fax:** (630) 852-6545
- **Mailing address:** 24 W FIRST ST, MANTENO, IL 60950-1239
- **Mailing address phone:** (630) 969-0036
- **Mailing address fax:** (630) 852-6545

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | 054009256 | IL | — |
| 3336C0003X | Community/Retail Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 12/13/2006
- **Last updated:** 06/12/2019

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2019413 | PK | — |