Provider Demographics
NPI:1053338418
Name:K -VA -T FOOD STORES INC
Entity type:Organization
Organization Name:K -VA -T FOOD STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-623-5100
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 S ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-7675
Practice Address - Country:US
Practice Address - Phone:423-979-0373
Practice Address - Fax:423-979-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
TN3887333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4436451OtherNCPDP
TN4059488OtherBCBS TENNESSEE
4436451OtherOTHER ID NUMBER-COMMERCIAL NUMBER
600002658OtherRAILROAD MEDICARE
VA008520330Medicaid
VA009999426OtherMEDICAID DME VA
TN1454311OtherTENNCARE DME CROSSOVER
278425OtherANTHEM BCBS
3913901OtherMEDICARE FLU SHOTS