Organization
DOUGLAS & OGDEN MEDICAL CENTER PHARMACY INC
Active
Other names
Main Street Pharmacy, DOUGLAS MAIN PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CLARKE ALLAN KUELTZO PHARMD (PRESIDENT)
(630) 969-0036
Entity
Organization
Contact information
Practice address
24 W FIRST ST, MANTENO, IL 60950-1239
(630) 969-0036
(630) 852-6545
Mailing address
24 W FIRST ST, MANTENO, IL 60950-1239
(630) 969-0036
(630) 852-6545
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
054009256
IL
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2019413
PK
—
Enumeration date
12/13/2006
Last updated
06/12/2019
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