Provider Demographics
NPI:1518259613
Name:HARRIS TEETER PHARMACY #208
Entity Type:Organization
Organization Name:HARRIS TEETER PHARMACY #208
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-366-5684
Mailing Address - Street 1:112 S SHARON AMITY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2802
Mailing Address - Country:US
Mailing Address - Phone:704-366-5684
Mailing Address - Fax:704-366-1598
Practice Address - Street 1:112 S SHARON AMITY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2802
Practice Address - Country:US
Practice Address - Phone:704-366-5684
Practice Address - Fax:704-366-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-07
Last Update Date:2011-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC159373336C0003X
SC123253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy