Healthcare Provider Details

I. General information

NPI: 1316964778
Provider Name (Legal Business Name): K VA T FOOD STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 BROAD ST VILLAGE SHOPPING CTR
ELIZABETHTON TN
37643-2315
US

IV. Provider business mailing address

PO BOX 1158
ABINGDON VA
24212-1158
US

V. Phone/Fax

Practice location:
  • Phone: 423-542-4925
  • Fax: 423-542-6744
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number4068
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STEVEN C SMITH
Title or Position: PRESIDENT & CEO
Credential:
Phone: 276-623-5100