Healthcare Provider Details

I. General information

NPI: 1417901646
Provider Name (Legal Business Name): KILGORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N PROVIDENCE RD
COLUMBIA MO
65203-4373
US

IV. Provider business mailing address

700 N PROVIDENCE RD
COLUMBIA MO
65203-4373
US

V. Phone/Fax

Practice location:
  • Phone: 573-442-0194
  • Fax: 573-443-8253
Mailing address:
  • Phone: 573-442-0194
  • Fax: 573-443-8253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2008000930
License Number StateMO

VIII. Authorized Official

Name: ANN BROMSTEDT
Title or Position: OWNER
Credential:
Phone: 573-442-0194