Provider Demographics
NPI:1194922930
Name:HARRIS TEETER LLC
Entity type:Organization
Organization Name:HARRIS TEETER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BREDESTEGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
Mailing Address - Street 1:701 CRESTDALE RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1700
Mailing Address - Country:US
Mailing Address - Phone:704-844-3100
Mailing Address - Fax:704-844-6556
Practice Address - Street 1:3600 SOUTH GLEBE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202
Practice Address - Country:US
Practice Address - Phone:703-412-9144
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010041673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194922930Medicaid
4840193OtherNABP
FH0396021OtherDEA
4840193OtherNABP