Provider Demographics
NPI:1215954672
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 1:3004 US HIGHWAY 23 N
Practice Address - Street 2:
Practice Address - City:WEBER CITY
Practice Address - State:VA
Practice Address - Zip Code:24290-7087
Practice Address - Country:US
Practice Address - Phone:276-386-2118
Practice Address - Fax:276-386-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
VA0201003703333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3150569OtherBCBS OF TENNESSEE
VA009104275OtherVA MEDICAID DME
P00364986OtherRAILROAD MEDICARE
VA008501467Medicaid
4835495OtherNCPDP
4835495OtherOTHER ID NUMBER-COMMERCIAL NUMBER
384788OtherANTHEM BCBS
384788OtherANTHEM BCBS
VA009104275OtherVA MEDICAID DME