Provider Demographics
NPI:1679806517
Name:HARRIS TEETER, LLC
Entity type:Organization
Organization Name:HARRIS TEETER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PHARMACY ACCOUNTIG
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:W
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:28105-1700
Mailing Address - Country:US
Mailing Address - Phone:704-844-3100
Mailing Address - Fax:704-844-6556
Practice Address - Street 1:8184 WESTSIDE BLVD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2587
Practice Address - Country:US
Practice Address - Phone:301-362-5761
Practice Address - Fax:301-362-5273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPO50683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
21-34877OtherNCPDP
MD026017700Medicaid
MD026017700Medicaid
MD026017700Medicaid