Provider Demographics
NPI:1609974633
Name:KILGORE EXPRESS PHARMACY INC
Entity Type:Organization
Organization Name:KILGORE EXPRESS PHARMACY INC
Other - Org Name:KILGORE EXPRESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
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:256-845-6640
Mailing Address - Fax:256-845-9796
Practice Address - Street 1:103 GREENHILL BLVD NW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-3701
Practice Address - Country:US
Practice Address - Phone:256-845-6640
Practice Address - Fax:256-845-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
AL1126803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1995543OtherPK
AL009935092Medicaid
AL100003635Medicaid
AL009935092Medicaid