Provider Demographics
NPI:1760576243
Name:HARRIS TEETER, LLC
Entity Type:Organization
Organization Name:HARRIS TEETER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER PHARMACY LICENSING
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:PO BOX 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2772
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:
Practice Address - Street 1:20070 ASHBROOK COMMONS PLZ
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5034
Practice Address - Country:US
Practice Address - Phone:571-233-0517
Practice Address - Fax:571-223-0542
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
VA02010040303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4838744OtherNCBP
VA010192587Medicaid
VA010192587Medicaid
1226450065Medicare NSC