1184879488 NPI number — K-VA-T FOOD STORES, INC.

Table of content: (NPI 1184879488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184879488 NPI number — K-VA-T FOOD STORES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
K-VA-T FOOD STORES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FOOD CITY PHARMACY #699
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184879488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABINGDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24212-1158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-623-5100
Provider Business Mailing Address Fax Number:
276-623-5440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6681 BRISTOL HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PINEY FLATS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37686-5206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-538-0253
Provider Business Practice Location Address Fax Number:
423-538-0358
Provider Enumeration Date:
12/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHAIRMAN, PRESIDENT & CEO
Authorized Official Telephone Number:
276-623-5100

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1516905 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1184879488 . This is a "VA MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4208798 . This is a "BC BS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 361700 . This is a "ANTHEM BC BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4441969 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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