1619154341 NPI number — HARRIS TEETER LLC

Table of content: (NPI 1619154341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619154341 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:
HARRIS TEETER PHARMACY #350
Provider Other Organization Name Type Code:
3
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:
1619154341
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:
5060 FERRELL PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-467-2058
Provider Business Practice Location Address Fax Number:
704-844-6556
Provider Enumeration Date:
01/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BREDESTEGE
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY LICENSING MANAGER
Authorized Official Telephone Number:
513-762-1019

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  201004214 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4840713 . This is a "NABP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1619154341 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7704889 . This is a "MEDICAID DME" identifier . This identifiers is of the category "OTHER".




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