Healthcare Provider Details

I. General information

NPI: 1215299383
Provider Name (Legal Business Name): HARRIS TEETER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15080 IDLEWILD RD STE P
MATTHEWS NC
28104-3601
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284
US

V. Phone/Fax

Practice location:
  • Phone: 704-882-2297
  • Fax: 704-882-2311
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ALLISON BREDESTEGE
Title or Position: MANAGER OF PHARAMCY LICENSING
Credential:
Phone: 513-762-1019