Healthcare Provider Details

I. General information

NPI: 1497769491
Provider Name (Legal Business Name): KILGORE EXPRESS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 BANK ST
STEVENSON AL
35772-3781
US

IV. Provider business mailing address

PO BOX 680905
FORT PAYNE AL
35968-1610
US

V. Phone/Fax

Practice location:
  • Phone: 256-437-2248
  • Fax: 256-437-9003
Mailing address:
  • Phone: 256-437-2248
  • Fax: 256-437-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number107218
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100002584
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier1992953
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

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