Basic Information
| Provider Information | |||||||||
| NPI: | 1356927487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARRIS TEETER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842772 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022842772 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4550 KING ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223021307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2021 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | ANDREWS | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER OF PHARMACY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 5137621090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.