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	333600000X	Pharmacy	3357	TN
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3913901	OTHER		MEDICARE FLU SHOT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	4432883	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
3	4432883	OTHER		NCPDP
4	3104455	OTHER	TN	BCBS OF TENNESSEE
5	1454307	OTHER	TN	TENNCARE DME CROSSOVER
6	103110	OTHER		ANTHEM BCBS

General Provider Information

NPI Number	:	1881611234
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	:	1205 N EASTMAN RD
Second Line	:	CROWN POINT CENTER
City	:	KINGSPORT
State	:	TN
Zip	:	37664-3145
Country	:	US
Telephone Number	:	423-247-1961
Fax Number	:	423-247-2370

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	:	09/19/2007

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

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