Provider Demographics
NPI:1497048763
Name:HARRIS TEETER 046
Entity Type:Organization
Organization Name:HARRIS TEETER 046
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-599-8670
Mailing Address - Street 1:9641 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8706
Mailing Address - Country:US
Mailing Address - Phone:704-599-8670
Mailing Address - Fax:704-599-8498
Practice Address - Street 1:9641 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8706
Practice Address - Country:US
Practice Address - Phone:704-599-8670
Practice Address - Fax:704-599-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0609767Medicaid