Provider Demographics
NPI:1851714026
Name:HARRIS TEETER,LLC
Entity Type:Organization
Organization Name:HARRIS TEETER,LLC
Other - Org Name:HARRIS TEETER PHARMACY #369
Other - Org Type:Doing Business As
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 ROAD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105
Mailing Address - Country:US
Mailing Address - Phone:704-844-3418
Mailing Address - Fax:
Practice Address - Street 1:4540 PRINCESS ANNE ROAD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:704-844-3418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy