Provider Demographics
NPI:1902991375
Name:HARRIS TEETER, LLC
Entity Type:Organization
Organization Name:HARRIS TEETER, LLC
Other - Org Name:HARRIS TEETER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER, PHARMACY ADMIN/AR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-844-6524
Mailing Address - Street 1:701 CRESTDALE RD.
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105
Mailing Address - Country:US
Mailing Address - Phone:704-844-3100
Mailing Address - Fax:704-844-6556
Practice Address - Street 1:2281 CLOVERDALE AVE.
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-773-0628
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08086332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3439773OtherNABP
NC0347080Medicaid
7703709OtherMEDICAID DME
BH7808782OtherDEA
3439773OtherNABP