Kilgore Pharmacy LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

KILGORE PHARMACY LLC

Doing business as

Killgore Pharmacy
Killlgore Pharmacy

Practice address

1909 Main St
Haynesville, LA 71038-4907

Phone

(318) 624-1122

Fax

(318) 624-3343

NPI assigned

Feb 27, 2023

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Oluwafemi Adegboyega

Title

Owner

Phone

(708) 945-0269

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 2

• Killgore Pharmacy Doing business as
• Killlgore Pharmacy Doing business as

Medicare fee-for-service enrollment

Enrolled in LA

Enrollment records 1

Tax ID family

Kilgore Pharmacy LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Kilgore Pharmacy LLC

  • Long Term Care Pharmacy
  • Haynesville, LA
  • NPI 1902670243
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1677456000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746230400000",
    "number": "1972202067",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1909 MAIN ST",
            "city": "HAYNESVILLE",
            "state": "LA",
            "postal_code": "710384907",
            "telephone_number": "318-624-1122",
            "fax_number": "318-624-3343"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1909 MAIN ST",
            "city": "HAYNESVILLE",
            "state": "LA",
            "postal_code": "710384907",
            "telephone_number": "318-624-1122",
            "fax_number": "318-624-3343"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KILGORE PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-02-27",
        "last_updated": "2025-05-03",
        "certification_date": "2025-05-03",
        "status": "A",
        "authorized_official_last_name": "ADEGBOYEGA",
        "authorized_official_first_name": "OLUWAFEMI",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "708-945-0269"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2210017",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Killgore Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Killgore Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Killlgore Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Alice J Fanning, FNP
• Paula Herrington
• Homer Memorial Hospital (Butler-Abshire Medical Clinic)
• James K Killgore Inc (Killgores Pharmacy)
• Kilgore Pharmacy LLC
• Jacinda Meadors
• Sandra Killgore Meisler, PH
• Moseley E Mellinger, LPC, NCC
• Samantha Modisette
• Eddy Waller Sherman II, DDS

• Community/Retail Pharmacy in Haynesville, LA
• Providers in Haynesville, LA by specialty
• Community/Retail Pharmacy in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.