Provider Demographics
NPI:1356526974
Name:KILGORE EXPRESS PHARMCY INC
Entity type:Organization
Organization Name:KILGORE EXPRESS PHARMCY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
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:256-845-6796
Practice Address - Street 1:5999 HIGHWAY 72 E
Practice Address - Street 2:
Practice Address - City:GURLEY
Practice Address - State:AL
Practice Address - Zip Code:35748-9460
Practice Address - Country:US
Practice Address - Phone:256-776-4430
Practice Address - Fax:256-776-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1119893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0134988OtherNCPDP PROVIDER IDENTIFICATION NUMBER