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	09279	NC
2	3336C0003X	Community/Retail Pharmacy	09279	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3405683	OTHER	NABP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952419582
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	:	9720 REA RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277
Country	:	US
Telephone Number	:	704-752-1164
Fax Number	:	704-844-6556

Authorized Official
Title or Position	:	MANAGER PHARMACY ACCT/AR
Name	:	ROSE WARD
Credential	:
Telephone Number	:	704-844-6524

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	03/07/2023

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Directions to “HARRIS TEETER, LLC ” Practice Location

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