Provider Demographics
NPI:1710158126
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 LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
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:513-762-1019
Mailing Address - Fax:
Practice Address - Street 1:134 TOWN CENTER DR
Practice Address - Street 2:SUITE H
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9158
Practice Address - Country:US
Practice Address - Phone:704-799-1066
Practice Address - Fax:704-844-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497678Medicaid
7704929OtherMEDICAID DME
3410711OtherNABP
3410711OtherNABP
FH0768791OtherDEA