Provider Demographics
NPI:1568489045
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:HWY 11 145 W LEE HWY
Practice Address - Street 2:
Practice Address - City:CHILHOWIE
Practice Address - State:VA
Practice Address - Zip Code:24319
Practice Address - Country:US
Practice Address - Phone:276-646-2941
Practice Address - Fax:276-646-5147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
VA0201003922333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010003849Medicaid
4837425OtherNCPDP
142351OtherANTHEM BCBS
4837425OtherOTHER ID NUMBER-COMMERCIAL NUMBER
P00364986OtherRAILROAD MEDICARE
VA010003857OtherVA MEDICAID DME
TN4075195OtherBCBS OF TENNESSEE
1235320044Medicare NSC
P00364986OtherRAILROAD MEDICARE