Healthcare Provider Details

I. General information

NPI: 1659475085
Provider Name (Legal Business Name): HARRIS TEETER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

6610 OLD MONROE RD.
INDIAN TRAIL NC
28079
US

IV. Provider business mailing address

701 CRESTDALE RD
MATTHEWS NC
28105-1700
US

V. Phone/Fax

Practice location:
  • Phone: 704-289-1193
  • Fax: 704-844-6556
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 Number09041
License Number StateNC

VIII. Authorized Official

Name: JESSICA WARMAN
Title or Position: MANAGER RX LICENSING
Credential:
Phone: 513-762-1019