1114944691 NPI number — K VA T FOOD STORES INC

Table of content: (NPI 1114944691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114944691 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:
Provider Other Organization Name Type Code:
6
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:
1114944691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2021
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:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1235 BONHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24202-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-669-2388
Provider Business Practice Location Address Fax Number:
276-669-2721
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
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 , with the licence number: 0201003682 , 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" .

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

  • Identifier: 3149004 . This is a "BCBS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4834657 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008505187 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009102787 . This is a "VA MEDICAID DME" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00364986 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102489 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4834657 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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