Provider Demographics
NPI:1093142796
Name:HARRIS TEETER, LLC
Entity Type:Organization
Organization Name:HARRIS TEETER, LLC
Other - Org Name:HARRIS TEETER #409
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBLITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-844-3418
Mailing Address - Street 1:22700 SWEET SHRUB DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-3328
Mailing Address - Country:US
Mailing Address - Phone:301-916-7290
Mailing Address - Fax:301-916-7288
Practice Address - Street 1:22700 SWEET SHRUB DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871
Practice Address - Country:US
Practice Address - Phone:301-916-7290
Practice Address - Fax:301-916-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies