1275550758 NPI number — K VA T FOOD STORES INC

Table of content: (NPI 1275550758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275550758 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:
1275550758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2007
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:
284 MORRELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37919-5876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-691-1153
Provider Business Practice Location Address Fax Number:
865-691-8950
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: 3323 , registered in the state of TN ; 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: 4439180 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3913901 . This is a "MEDICARE FLU SHOTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4121928 . This is a "BCBS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4439180 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1455038 . This is a "TENNCARE DME" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 191691 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".




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