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	3336C0003X	Community/Retail Pharmacy	0201003968	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	48-38061	OTHER	NABP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588768816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRIS TEETER, LLC

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

Provider Business Practice Location Address
First Line	:	3333 VIRGINIA BCH BLVD. #101
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452
Country	:	US
Telephone Number	:	757-631-2415
Fax Number	:	704-844-6556

Authorized Official
Title or Position	:	MANAGER, PHARMACY ACCOUNTING
Name	:	ROSE WARD
Credential	:
Telephone Number	:	704-844-6534

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	03/07/2023

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Directions to “HARRIS TEETER, LLC ” Practice Location

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