Provider Demographics
NPI:1124045588
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:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:REED
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 1:205 RIVERBEND DRIVE, SUITE 102
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-2916
Practice Address - Country:US
Practice Address - Phone:276-546-6820
Practice Address - Fax:276-546-6897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
VA0201003908333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54005590Medicaid
KY90007113OtherKY MEDICAID DME
VA008519927Medicaid
TN4055731OtherBCBS OF TENNESSEE
P00364986OtherRAILROAD MEDICARE
464704OtherANTHEM BCBS
KY7100177630OtherKY MEDICAID
VA009120581OtherVA MEDICAID DME
4837223OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4837223OtherNCPDP
464704OtherANTHEM BCBS
VA008519927Medicaid