Provider Demographics
NPI:1508064999
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:DIRECTOR OF PHARMACY ACCT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-844-6524
Mailing Address - Street 1:701 CRESTDALE RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1700
Mailing Address - Country:US
Mailing Address - Phone:704-844-3100
Mailing Address - Fax:704-844-6556
Practice Address - Street 1:620 LONG POINTE ROAD
Practice Address - Street 2:SUITE H
Practice Address - City:MT. PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-856-4631
Practice Address - Fax:843-856-4875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5096553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC796557Medicaid
SC796557Medicaid
SC796557Medicaid