1487756870 NPI number — HARRIS TEETER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487756870 NPI number — HARRIS TEETER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARRIS TEETER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487756870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 CRESTDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTHEWS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28105-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-844-3100
Provider Business Mailing Address Fax Number:
704-844-6556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11516 PROVIDENCE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-841-4019
Provider Business Practice Location Address Fax Number:
704-844-6556
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WARD
Authorized Official First Name:
ROSE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, PHARMACY ADMIN/AR
Authorized Official Telephone Number:
704-844-6524

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  08188 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 08188 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3440459 . This is a "NABP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0609616 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7703808 . This is a "MEDICAID DME" identifier . This identifiers is of the category "OTHER".




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