Healthcare Provider Details

I. General information

NPI: 1952594004
Provider Name (Legal Business Name): KILGORE EXPRESS PHARMCY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

588 S VALLEY AVE
COLLINSVILLE AL
35961-3535
US

IV. Provider business mailing address

PO BOX 680905
FORT PAYNE AL
35968-1610
US

V. Phone/Fax

Practice location:
  • Phone: 256-524-2981
  • Fax: 256-524-2987
Mailing address:
  • Phone: 256-845-6640
  • Fax: 256-845-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number112980
License Number StateAL

VIII. Authorized Official

Name: LOTHA KILGORE
Title or Position: OWNER
Credential: RPH
Phone: 256-845-6640