Provider Demographics
NPI:1578958146
Name:K VA T FOOD STORES INC.
Entity Type:Organization
Organization Name:K VA T FOOD STORES INC.
Other - Org Name:FOOD CITY PHARMACY #622
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN PRESIDENT CEO
Authorized Official - Prefix:MR
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:276-623-5100
Mailing Address - Fax:276-623-5440
Practice Address - Street 1:1317 VIRGINIA AVE
Practice Address - Street 2:HWY 421
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-5158
Practice Address - Country:US
Practice Address - Phone:276-623-5100
Practice Address - Fax:276-623-5440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2016-07-04
Deactivation Date:2016-01-25
Deactivation Code:
Reactivation Date:2016-02-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021826OtherMEDICAID DME
TN600002658Medicare PIN
TNQ021826OtherMEDICAID DME
TN3913901Medicare PIN