Provider Demographics
NPI:1629416557
Name:HARRIS TEETER LLC
Entity Type:Organization
Organization Name:HARRIS TEETER LLC
Other - Org Name:
Other - Org Type:
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 1:701 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:704-844-3418
Mailing Address - Fax:704-844-6512
Practice Address - Street 1:2120 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1722
Practice Address - Country:US
Practice Address - Phone:919-731-2423
Practice Address - Fax:919-731-9918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1226450160Medicare NSC