1760543581 NPI number — DOUGLAS & OGDEN MEDICAL CENTER PHARMACY INC

Table of content: (NPI 1760543581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760543581 NPI number — DOUGLAS & OGDEN MEDICAL CENTER PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS & OGDEN MEDICAL CENTER PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAIN STREET PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760543581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 W FIRST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTENO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60950-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-969-0036
Provider Business Mailing Address Fax Number:
630-852-6545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 W FIRST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTENO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60950-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-969-0036
Provider Business Practice Location Address Fax Number:
630-852-6545
Provider Enumeration Date:
12/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KUELTZO
Authorized Official First Name:
CLARKE
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-969-0036

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054009256 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2019413 . This is a "PK" identifier . This identifiers is of the category "OTHER".