1124045588 NPI number — K -VA -T FOOD STORES INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124045588 NPI number — K -VA -T FOOD STORES INC

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 Other Organization Name:

FOOD CITY PHARMACY

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:

1124045588

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

03/30/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

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:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

205 RIVERBEND DRIVE, SUITE 102

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PENNINGTON GAP

Provider Business Practice Location Address State Name:

VA

Provider Business Practice Location Address Postal Code:

24277-2916

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

276-546-6820

Provider Business Practice Location Address Fax Number:

276-546-6897

Provider Enumeration Date:

07/15/2006

Authorized Official Last Name:

REED

Authorized Official First Name:

CONNIE

Authorized Official Middle Name:

ANN

Authorized Official Title or Position:

ADMINISTRATIVE ASSISTANT

Authorized Official Telephone Number:

276-623-5100

• Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 333600000X , with the licence number: 0201003908 , registered in the state of VA ; 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" .

• Identifier: 54005590 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: 90007113 . This is a "KY MEDICAID DME" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 008519927 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 4055731 . This is a "BCBS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: P00364986 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 464704 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
• Identifier: 7100177630 . This is a "KY MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 009120581 . This is a "VA MEDICAID DME" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 4837223 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 4837223 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".