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	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy	3887	TN
3	3336C0003X	Community/Retail Pharmacy

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	600002658	OTHER		RAILROAD MEDICARE
9	3913901	OTHER		MEDICARE FLU SHOTS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4436451	OTHER		NCPDP
2	4059488	OTHER	TN	BCBS TENNESSEE
3	4436451	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	1454311	OTHER	TN	TENNCARE DME CROSSOVER
8	278425	OTHER		ANTHEM BCBS

General Provider Information

NPI Number	:	1053338418
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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 S ROAN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-7675
Country	:	US
Telephone Number	:	423-979-0373
Fax Number	:	423-979-0372

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

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	03/06/2024

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

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