Provider Demographics
NPI:1639262363
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:MANAGER, PHARMACY ADMIN/AR
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:704-844-6525
Mailing Address - Street 1:1014 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:3565 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-2209
Practice Address - Country:US
Practice Address - Phone:252-637-9537
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC06181332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
7703105OtherMEDICIAD DME
NC0255620Medicaid
3432692OtherNABP
3432692OtherNABP
1226450004Medicare NSC