1730415142 NPI number — KILGORE EXPRESS PHARMACY INC

Table of content: (NPI 1730415142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730415142 NPI number — KILGORE EXPRESS PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KILGORE EXPRESS PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KILGORE EXPRESS PHARMACY #6
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730415142
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 680905
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PAYNE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35968-1610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-845-6640
Provider Business Mailing Address Fax Number:
256-845-9796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1614 GLENN BLVD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PAYNE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35968-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-845-3402
Provider Business Practice Location Address Fax Number:
256-845-3289
Provider Enumeration Date:
10/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
LOTHA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
256-845-3402

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  113311 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0136209 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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