Healthcare Provider Details

I. General information

NPI: 1184716011
Provider Name (Legal Business Name): HARRIS TEETER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19815 NORTH COVE RD.
CORNELIUS NC
28031
US

IV. Provider business mailing address

701 CRESTDALE RD.
MATTHEWS NC
28105
US

V. Phone/Fax

Practice location:
  • Phone: 704-895-5075
  • Fax: 704-844-6556
Mailing address:
  • Phone: 704-844-3100
  • Fax: 704-844-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number07057
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number07057
License Number StateNC

VIII. Authorized Official

Name: ROSE WARD
Title or Position: MANAGER, PHARMACY ADMIN/AR
Credential:
Phone: 704-844-6524