Provider Demographics
NPI:1417901646
Name:KILGORE INC
Entity Type:Organization
Organization Name:KILGORE INC
Other - Org Name:KILGORE'S MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROMSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-442-0194
Mailing Address - Street 1:700 N PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4373
Mailing Address - Country:US
Mailing Address - Phone:573-442-0194
Mailing Address - Fax:573-443-8253
Practice Address - Street 1:700 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4373
Practice Address - Country:US
Practice Address - Phone:573-442-0194
Practice Address - Fax:573-443-8253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X
MO20080009303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO850587205Medicaid
2047047OtherPK
MO600587208Medicaid
MO620587204Medicaid
MO600587205Medicaid
MO850587205Medicaid