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General NPI Number Information
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NPI Number | 1518259613
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Entity Type | Organization
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Legal Business Name | HARRIS TEETER PHARMACY #208
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Dates
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Enumeration Date | 05/07/2011
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Last Update Date | 05/07/2011
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Provider Practice Location Address
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Address Line | 112 S SHARON AMITY RD
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City | CHARLOTTE
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State | NC
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Zip | 28211-2802
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Country | US
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Telephone | 704-366-5684
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Fax | 704-366-1598
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Provider Business Mailing Address
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Address Line | 112 S SHARON AMITY RD
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City | CHARLOTTE
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State | NC
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Zip | 28211-2802
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Country | US
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Telephone | 704-366-5684
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Fax | 704-366-1598
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | DR. JONATHAN GADDY
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Credential | PHARMD
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Telephone | 704-366-5684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 12325
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 15937
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License Number State | NC
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