Provider Demographics
NPI:1699877092
Name:HARRIS TEETER, LLC
Entity type:Organization
Organization Name:HARRIS TEETER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER RX LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARMAN
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 1:5810 HIGHLAND SHOPPES DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-2646
Practice Address - Country:US
Practice Address - Phone:704-875-7128
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09297332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
7704664OtherMEDICAID DME
NC0601002Medicaid
3405897OtherNABP
BH9705736OtherDEA
1226450097Medicare NSC