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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1467861161
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	:	704-844-3418
Fax Number	:

Provider Business Practice Location Address
First Line	:	735 N SAINT ASAPH ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-1911
Country	:	US
Telephone Number	:	704-844-3418
Fax Number	:

Authorized Official
Title or Position	:	LICENSE ADMINISTRATOR
Name	:	MARY K NOBLITT
Credential	:
Telephone Number	:	704-844-3418

Provider Enumeration Date	:	08/06/2014
Last Update Date	:	08/06/2014

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