=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831293265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARRIS TEETER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1955 N PEACEHAVEN RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-765-6285
-----------------------------------------------------
Fax | 704-844-6556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 842772
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02284-2772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-669-3225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER PHARMACY LICENSING
-----------------------------------------------------
Name | ALLISON BREDESTEGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-762-1019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 08060
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 08060
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------