MEDICARE: HARRIS TEETER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	07267	NC
2	3336C0003X	Community/Retail Pharmacy	07267	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3436347	OTHER	NABP

General Provider Information

NPI Number	:	1366546699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRIS TEETER, LLC

Provider Business Mailing Address
First Line	:	701 CRESTDALE RD
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-1700
Country	:	US
Telephone Number	:	704-844-3100
Fax Number	:	704-844-6556

Provider Business Practice Location Address
First Line	:	4701 SMITH FARM RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216
Country	:	US
Telephone Number	:	704-949-2211
Fax Number	:	980-256-3442

Authorized Official
Title or Position	:	MANAGER PHARMACY LICENSING
Name	:	JESSIE WARMAN
Credential	:
Telephone Number	:	513-762-1090

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	03/07/2023

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Directions to “HARRIS TEETER, LLC ” Practice Location

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