Provider Demographics
NPI:1003928524
Name:HARRIS TEETER LLC
Entity Type:Organization
Organization Name:HARRIS TEETER LLC
Other - Org Name:HARRIS TEETER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BREDESTEGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
Mailing Address - Street 1:PO BOX 2918
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67504-2918
Mailing Address - Country:US
Mailing Address - Phone:620-694-5550
Mailing Address - Fax:704-844-6556
Practice Address - Street 1:701 FRANCIS KING ST.
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410
Practice Address - Country:US
Practice Address - Phone:336-834-8028
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08107332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0417998Medicaid
7703710OtherMEDICAID DME
3439999OtherNABP
3439999OtherNABP
7703710OtherMEDICAID DME