Healthcare Provider Details

I. General information

NPI: 1730415142
Provider Name (Legal Business Name): KILGORE EXPRESS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 GLENN BLVD SW
FORT PAYNE AL
35968-3522
US

IV. Provider business mailing address

PO BOX 680905
FORT PAYNE AL
35968-1610
US

V. Phone/Fax

Practice location:
  • Phone: 256-845-3402
  • Fax: 256-845-3289
Mailing address:
  • Phone: 256-845-6640
  • Fax: 256-845-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number113311
License Number StateAL

VIII. Authorized Official

Name: LOTHA KILGORE
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 256-845-3402