Healthcare Provider Details

I. General information

NPI: 1497121768
Provider Name (Legal Business Name): K VA T FOOD STORES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 HIXSON PIKE
HIXSON TN
37343-3243
US

IV. Provider business mailing address

PO BOX 1158
ABINGDON VA
24212-1158
US

V. Phone/Fax

Practice location:
  • Phone: 423-842-7482
  • Fax: 423-842-7483
Mailing address:
  • Phone: 276-623-5100
  • Fax: 276-623-5440

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 Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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