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	08483	NC
2	3336C0003X	Community/Retail Pharmacy	08483	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3441982	OTHER	NABP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922102672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARRIS TEETER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:

Provider Business Practice Location Address
First Line	:	5920 WEDDINGTON-MONROE RD.
Second Line	:
City	:	WESLEY CHAPEL
State	:	NC
Zip	:	28104
Country	:	US
Telephone Number	:	704-843-0433
Fax Number	:	704-844-6556

Authorized Official
Title or Position	:	PHARMACY LICENSING MANAGER
Name	:	ALLISON BREDESTEGE
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	03/07/2023

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Directions to “HARRIS TEETER, LLC ” Practice Location

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