Provider Demographics
NPI:1962811893
Name:HARRIS TEETER PHARMACY #63
Entity type:Organization
Organization Name:HARRIS TEETER PHARMACY #63
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:252-937-2161
Mailing Address - Street 1:3679 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3411
Mailing Address - Country:US
Mailing Address - Phone:252-937-2161
Mailing Address - Fax:252-451-2594
Practice Address - Street 1:3679 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3411
Practice Address - Country:US
Practice Address - Phone:252-937-2161
Practice Address - Fax:252-451-2594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC237443336C0003X
VA2022121873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy