MEDICARE: HARRIS TEETER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1235636515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRIS TEETER LLC

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 GREAT NECK SQ
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2202
Country	:	US
Telephone Number	:	757-481-5458
Fax Number	:

Authorized Official
Title or Position	:	LICENSING MANAGER
Name	:	ALLISON BREDESTEGE
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/19/2018

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Directions to “HARRIS TEETER LLC ” Practice Location

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