Provider Demographics
NPI:1619154341
Name:HARRIS TEETER LLC
Entity Type:Organization
Organization Name:HARRIS TEETER LLC
Other - Org Name:HARRIS TEETER PHARMACY #350
Other - Org Type:Doing Business As
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 1:701 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 1:5060 FERRELL PARKWAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464
Practice Address - Country:US
Practice Address - Phone:757-467-2058
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2010042143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4840713OtherNABP
VA1619154341Medicaid
7704889OtherMEDICAID DME
FH0715219OtherDEA
1226450116Medicare NSC