Provider Demographics
NPI:1497769491
Name:KILGORE EXPRESS PHARMACY INC
Entity Type:Organization
Organization Name:KILGORE EXPRESS PHARMACY INC
Other - Org Name:NORTH JACKSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOTHA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-845-6640
Mailing Address - Street 1:PO BOX 680905
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-1610
Mailing Address - Country:US
Mailing Address - Phone:256-437-2248
Mailing Address - Fax:256-437-9003
Practice Address - Street 1:85 BANK ST
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:AL
Practice Address - Zip Code:35772-3781
Practice Address - Country:US
Practice Address - Phone:256-437-2248
Practice Address - Fax:256-437-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1072183336C0003X, 3336C0003X
332BX2000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002584Medicaid
1992953OtherPK
1126230001Medicare NSC