Healthcare Provider Details

I. General information

NPI: 1679806517
Provider Name (Legal Business Name): HARRIS TEETER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8184 WESTSIDE BLVD
FULTON MD
20759-2587
US

IV. Provider business mailing address

701 CRESTDALE RD
MATTHEWS NC
28105-1700
US

V. Phone/Fax

Practice location:
  • Phone: 301-362-5761
  • Fax: 301-362-5273
Mailing address:
  • Phone: 704-844-3100
  • Fax: 704-844-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPO5068
License Number StateMD

VIII. Authorized Official

Name: ROSE W WARD
Title or Position: MANAGER, PHARMACY ACCOUNTIG
Credential:
Phone: 704-844-6524