1639353733 NPI number — K VA T FOOD STORES INC

Table of content: (NPI 1639353733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639353733 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:
1639353733
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:
2946 WINFIELD DUNN PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KODAK
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37764-4309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-933-4676
Provider Business Practice Location Address Fax Number:
865-933-4501
Provider Enumeration Date:
12/26/2007

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 ; 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: 1455265 . This is a "TN CROSSOVER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 344784 . This is a "ANTHEM BCBS MEDIGAP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4440955 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 600002658 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4171342 . This is a "BC BS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".