Provider Demographics
NPI:1184879488
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: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 1:6681 BRISTOL HIGHWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:PINEY FLATS
Practice Address - State:TN
Practice Address - Zip Code:37686-5206
Practice Address - Country:US
Practice Address - Phone:423-538-0253
Practice Address - Fax:423-538-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516905Medicaid
1184879488OtherVA MEDICAID
TN4208798OtherBC BS TN
361700OtherANTHEM BC BS
4441969OtherNCPDP
TN3913901Medicare PIN
600002658Medicare PIN
TN1516905Medicaid