Provider Demographics
NPI:1114310224
Name:K-VAT FOOD STORES, INC
Entity Type:Organization
Organization Name:K-VAT FOOD STORES, INC
Other - Org Name:COOKE'S PHARMACY- OCOEE
Other - Org Type:Doing Business As
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:ATTN: CONNIE REED
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-1158
Mailing Address - Country:US
Mailing Address - Phone:276-623-5100
Mailing Address - Fax:276-623-5440
Practice Address - Street 1:116 WHITE WATER DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:TN
Practice Address - Zip Code:37361-3644
Practice Address - Country:US
Practice Address - Phone:423-216-0050
Practice Address - Fax:423-216-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000055323336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ036789Medicaid
2150719OtherPK