MEDICARE: K VA T FOOD STORES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4277861	OTHER		BLUE CROSS BLUE SHIELD OF TN
2	4443571	OTHER	TN	NCPDP
3	4277861	OTHER	TN	BC BS TN
4	1523264	OTHER	TN	TENNCARE CROSSOVER
5	414557	OTHER	TN	ANTHEM BCBS

General Provider Information

NPI Number	:	1811205404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K VA T FOOD STORES INC

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

Provider Business Practice Location Address
First Line	:	4100 COOL SPRINGS ROAD
Second Line	:
City	:	MORRISTOWN
State	:	TN
Zip	:	37814
Country	:	US
Telephone Number	:	423-317-5020
Fax Number	:	423-318-6999

Authorized Official
Title or Position	:	CHAIRMAN PRESIDENT & CEO
Name	:	MR. STEVEN C SMITH
Credential	:
Telephone Number	:	276-623-5100

Provider Enumeration Date	:	09/17/2010
Last Update Date	:	02/07/2012

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Directions to “K VA T FOOD STORES INC ” Practice Location

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